Provider Demographics
NPI:1669920385
Name:VAUGHN, JENNA (PHARMD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E GREENWAY PKWY
Mailing Address - Street 2:APT 2007
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-2527
Mailing Address - Country:US
Mailing Address - Phone:719-964-5641
Mailing Address - Fax:
Practice Address - Street 1:23620 N 20TH DR
Practice Address - Street 2:SUITE 12
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-0621
Practice Address - Country:US
Practice Address - Phone:877-546-5779
Practice Address - Fax:877-546-5780
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS022155183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS022155OtherARIZONA PHARMACIST LICENSE