Provider Demographics
NPI:1649883380
Name:CARR, JACLYN MARIE (PHARM D)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:CARR
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2227 JULES ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2715
Mailing Address - Country:US
Mailing Address - Phone:618-910-4486
Mailing Address - Fax:
Practice Address - Street 1:4140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-4604
Practice Address - Country:US
Practice Address - Phone:314-832-4995
Practice Address - Fax:314-832-6636
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296928183500000X
MO2014006413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist