Provider Demographics
NPI:1255936159
Name:DAUGHERTY, JARED (PHARMD)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:DAUGHERTY
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 1:1571 N DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2653
Mailing Address - Country:US
Mailing Address - Phone:270-737-0352
Mailing Address - Fax:
Practice Address - Street 1:1571 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2653
Practice Address - Country:US
Practice Address - Phone:270-737-0352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY020085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist