Provider Demographics
NPI:1205111424
Name:MYERS, JASEN L (PHARMD)
Entity type:Individual
Prefix:
First Name:JASEN
Middle Name:L
Last Name:MYERS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 PINE AVE W
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-1311
Mailing Address - Country:US
Mailing Address - Phone:715-235-9275
Mailing Address - Fax:715-235-9287
Practice Address - Street 1:121 PINE AVE W
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-1311
Practice Address - Country:US
Practice Address - Phone:715-235-9275
Practice Address - Fax:715-235-9287
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13899-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist