Provider Demographics
NPI:1245877018
Name:WHITWAM, JAKE JAMES (PHARMD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:JAMES
Last Name:WHITWAM
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 1:41848 W BARCELONA DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-3663
Mailing Address - Country:US
Mailing Address - Phone:760-805-1626
Mailing Address - Fax:
Practice Address - Street 1:1514 E FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4741
Practice Address - Country:US
Practice Address - Phone:520-836-2787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-28
Last Update Date:2019-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024304183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist