Provider Demographics
NPI:1811598378
Name:CONNERS, JEROME
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:CONNERS
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 1:100 MCGINNIS DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:WV
Mailing Address - Zip Code:25570-9691
Mailing Address - Country:US
Mailing Address - Phone:304-272-3766
Mailing Address - Fax:304-272-5067
Practice Address - Street 1:100 MCGINNIS DR
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:WV
Practice Address - Zip Code:25570-9691
Practice Address - Country:US
Practice Address - Phone:304-272-3766
Practice Address - Fax:304-272-5067
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0006475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist