Provider Demographics
NPI:1922103498
Name:DISTEFANO, JEANINE (RPH, JD)
Entity Type:Individual
Prefix:MS
First Name:JEANINE
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:RPH, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 EDGEMOOR LN
Mailing Address - Street 2:
Mailing Address - City:HONEY BROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19344-9601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 BLACKHORSE HILL RD
Practice Address - Street 2:DEPT. OF VET AFFAIRS MED CTR - #119
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-2040
Practice Address - Country:US
Practice Address - Phone:610-383-0284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP034351T183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist