Provider Demographics
NPI:1255710372
Name:GROAT, JACQUELINE L (PHARMD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
Last Name:GROAT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3372 E JENALAN
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7787
Mailing Address - Country:US
Mailing Address - Phone:208-262-8751
Mailing Address - Fax:
Practice Address - Street 1:3372 E JENALAN
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7787
Practice Address - Country:US
Practice Address - Phone:208-262-8751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60368614183500000X
IDP6917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist