Provider Demographics
NPI:1750639860
Name:WARNER, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:WARNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3818 N 43RD PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-5432
Mailing Address - Country:US
Mailing Address - Phone:602-434-5497
Mailing Address - Fax:
Practice Address - Street 1:20631 N SCOTTSDALE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-6452
Practice Address - Country:US
Practice Address - Phone:480-563-1265
Practice Address - Fax:480-563-3780
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist