Provider Demographics
NPI:1740387620
Name:CARPENTER, JESSE WILLIAM (MBAHCM)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:WILLIAM
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:MBAHCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 W CORONADO RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-1148
Mailing Address - Country:US
Mailing Address - Phone:602-741-0366
Mailing Address - Fax:
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:602-239-3102
Practice Address - Fax:602-239-6734
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ006002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist