Provider Demographics
NPI:1760714828
Name:LAVENDER, MORRELL JEROME JR
Entity Type:Individual
Prefix:
First Name:MORRELL
Middle Name:JEROME
Last Name:LAVENDER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MORRELL
Other - Middle Name:JEROME
Other - Last Name:LEGHORN
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1705 CROSSROADS ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1840
Mailing Address - Country:US
Mailing Address - Phone:619-415-1203
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-31
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81495183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician