Provider Demographics
NPI:1649532847
Name:HERMINA, JACKLEEN W
Entity type:Individual
Prefix:
First Name:JACKLEEN
Middle Name:W
Last Name:HERMINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKLEEN
Other - Middle Name:W
Other - Last Name:HERMINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:4486 ROLLING MDWS
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6573
Mailing Address - Country:US
Mailing Address - Phone:410-419-5177
Mailing Address - Fax:
Practice Address - Street 1:8036 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-1084
Practice Address - Country:US
Practice Address - Phone:410-761-5441
Practice Address - Fax:410-787-9402
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist