Provider Demographics
NPI:1730464892
Name:PEREZ, JESSICA INES (RPH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:INES
Last Name:PEREZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111
Mailing Address - Country:US
Mailing Address - Phone:860-707-9672
Mailing Address - Fax:
Practice Address - Street 1:633 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2542
Practice Address - Country:US
Practice Address - Phone:860-346-7628
Practice Address - Fax:860-346-0090
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00113322183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0011322OtherRPH LIC/ REG NO