Provider Demographics
NPI:1245510072
Name:BANWARTH, JERRA LYNN (RPH FIACP)
Entity type:Individual
Prefix:
First Name:JERRA
Middle Name:LYNN
Last Name:BANWARTH
Suffix:
Gender:F
Credentials:RPH FIACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-3652
Mailing Address - Country:US
Mailing Address - Phone:530-669-7038
Mailing Address - Fax:530-669-1655
Practice Address - Street 1:250 W MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3652
Practice Address - Country:US
Practice Address - Phone:530-669-7038
Practice Address - Fax:530-669-1655
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY45990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist