Provider Demographics
NPI:1336453521
Name:JETER, CASANDRA BONITA (RPH)
Entity Type:Individual
Prefix:
First Name:CASANDRA
Middle Name:BONITA
Last Name:JETER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 W ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-1420
Mailing Address - Country:US
Mailing Address - Phone:215-223-8979
Mailing Address - Fax:215-227-0932
Practice Address - Street 1:2201 W ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-1420
Practice Address - Country:US
Practice Address - Phone:215-223-8979
Practice Address - Fax:215-227-0932
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP029008L1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1679663793OtherNPI