Provider Demographics
NPI:1720627029
Name:WEBBER, JACKIE RAE (R PH)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:RAE
Last Name:WEBBER
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 LANSING DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-6234
Mailing Address - Country:US
Mailing Address - Phone:319-540-1067
Mailing Address - Fax:319-447-0552
Practice Address - Street 1:3600 BUSINESS HIGHWAY 151
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302
Practice Address - Country:US
Practice Address - Phone:319-377-7216
Practice Address - Fax:319-447-0552
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18417183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist