Provider Demographics
NPI:1992829097
Name:ESTES, M JACKLYNN (RPH)
Entity Type:Individual
Prefix:MS
First Name:M
Middle Name:JACKLYNN
Last Name:ESTES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 OLD FARM RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477-9236
Mailing Address - Country:US
Mailing Address - Phone:802-434-5288
Mailing Address - Fax:
Practice Address - Street 1:108 CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-4034
Practice Address - Country:US
Practice Address - Phone:802-878-1118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT3178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT3178OtherSTACE LICENSE