Provider Demographics
NPI:1720361371
Name:CAVINESS, JASON (RPH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:CAVINESS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 N 16TH ST
Mailing Address - Street 2:APT 2035
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7150
Mailing Address - Country:US
Mailing Address - Phone:507-227-0536
Mailing Address - Fax:
Practice Address - Street 1:3411 NORTH 16TH STREET
Practice Address - Street 2:APT 2035
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5995
Practice Address - Country:US
Practice Address - Phone:507-227-0536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18545183500000X
AZS019365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist