Provider Demographics
NPI:1962859769
Name:BROWN, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BROWN
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 1:1734 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3356
Mailing Address - Country:US
Mailing Address - Phone:304-253-5556
Mailing Address - Fax:304-254-0534
Practice Address - Street 1:1734 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3356
Practice Address - Country:US
Practice Address - Phone:304-253-5556
Practice Address - Fax:304-254-0534
Is Sole Proprietor?:No
Enumeration Date:2016-05-21
Last Update Date:2016-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0006901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist