Provider Demographics
NPI:1720795511
Name:TAVARES, JENNIFER ANN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:TAVARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 E FALMOUTH HWY
Mailing Address - Street 2:
Mailing Address - City:EAST FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02536-6166
Mailing Address - Country:US
Mailing Address - Phone:508-540-8621
Mailing Address - Fax:
Practice Address - Street 1:419 E FALMOUTH HWY
Practice Address - Street 2:
Practice Address - City:EAST FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02536-6166
Practice Address - Country:US
Practice Address - Phone:508-540-8621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH24872183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist