Provider Demographics
NPI:1750653515
Name:WIDHALM, JACKIE MARY (RPH)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARY
Last Name:WIDHALM
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 1:5801 SUMMITVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3006
Mailing Address - Country:US
Mailing Address - Phone:509-965-6393
Mailing Address - Fax:509-965-5966
Practice Address - Street 1:5801 SUMMITVIEW AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3006
Practice Address - Country:US
Practice Address - Phone:509-965-6393
Practice Address - Fax:509-965-5966
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00015720183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist