Provider Demographics
NPI:1700401825
Name:HENDRA, JEREMIAH THOMAS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:THOMAS
Last Name:HENDRA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1240
Mailing Address - Country:US
Mailing Address - Phone:614-685-5004
Mailing Address - Fax:
Practice Address - Street 1:460 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210
Practice Address - Country:US
Practice Address - Phone:614-685-5004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03839612208U00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program