Provider Demographics
NPI:1205226503
Name:JACQUEMIN, RENEE
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:JACQUEMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7651 OLDTOWN RD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-8360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 S WASHINGTON ST
Practice Address - Street 2:PHARMACY DEPT
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2551
Practice Address - Country:US
Practice Address - Phone:419-238-8625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023688A183500000X
OHRPH.03230238-2183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist