Provider Demographics
NPI:1669877015
Name:ENEVOLDSEN, JADE (PHARM D)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:ENEVOLDSEN
Suffix:
Gender:M
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 1:4308 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5508
Mailing Address - Country:US
Mailing Address - Phone:307-745-6112
Mailing Address - Fax:307-721-4975
Practice Address - Street 1:4308 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5508
Practice Address - Country:US
Practice Address - Phone:307-745-6112
Practice Address - Fax:307-721-4975
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3784183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY3784OtherPHARMACIST LICENSE