Provider Demographics
NPI:1851997910
Name:PHACHANTRY, JENNIFER PHETSAMONE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PHETSAMONE
Last Name:PHACHANTRY
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 1:550 N HILLSIDE ST STE 3-100
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4910
Mailing Address - Country:US
Mailing Address - Phone:316-962-4210
Mailing Address - Fax:
Practice Address - Street 1:550 N HILLSIDE ST STE 3-100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4910
Practice Address - Country:US
Practice Address - Phone:316-962-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-109697183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist