Provider Demographics
NPI:1740766955
Name:MUDRICK, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MUDRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16580 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1217
Mailing Address - Country:US
Mailing Address - Phone:636-458-9934
Mailing Address - Fax:636-458-9274
Practice Address - Street 1:16580 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1217
Practice Address - Country:US
Practice Address - Phone:636-458-9934
Practice Address - Fax:636-458-9274
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009023456183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist