Provider Demographics
NPI:1942595061
Name:LAW, JIVONY W (RPH)
Entity Type:Individual
Prefix:MR
First Name:JIVONY
Middle Name:W
Last Name:LAW
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 1:2555 W 79TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1250
Mailing Address - Country:US
Mailing Address - Phone:952-888-4677
Mailing Address - Fax:
Practice Address - Street 1:2555 W 79TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1250
Practice Address - Country:US
Practice Address - Phone:952-888-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist