Provider Demographics
NPI:1699378141
Name:WILLOUGHBY, JENNIFER ROSE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ROSE
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 SECOFFEE TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-3194
Mailing Address - Country:US
Mailing Address - Phone:954-618-3940
Mailing Address - Fax:
Practice Address - Street 1:3215 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-5010
Practice Address - Country:US
Practice Address - Phone:305-569-1162
Practice Address - Fax:305-569-1167
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS46682183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS46682OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH