Provider Demographics
NPI:1811209489
Name:KLUCKEN, JAMIE LEE RIDLEY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:LEE RIDLEY
Last Name:KLUCKEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 MOORE PL SW
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-5808
Mailing Address - Country:US
Mailing Address - Phone:208-329-0653
Mailing Address - Fax:
Practice Address - Street 1:45085 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-2766
Practice Address - Country:US
Practice Address - Phone:703-726-8547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-11
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist