Provider Demographics
NPI:1790227510
Name:BAGLEY, JASON C (RPH)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 S 550 W
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-9030
Mailing Address - Country:US
Mailing Address - Phone:317-642-8174
Mailing Address - Fax:260-739-6696
Practice Address - Street 1:1326 N COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5526
Practice Address - Country:US
Practice Address - Phone:260-739-6069
Practice Address - Fax:260-739-6696
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018380A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26018380AOtherPHARMACIST STATE LICENSE