Provider Demographics
NPI:1740490150
Name:SPENCE, JON R (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:SPENCE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:PRINCESS ANNE
Mailing Address - State:MD
Mailing Address - Zip Code:21853-0191
Mailing Address - Country:US
Mailing Address - Phone:410-651-9852
Mailing Address - Fax:410-651-1279
Practice Address - Street 1:12145 ELM STREET
Practice Address - Street 2:
Practice Address - City:PRINCESS ANNE
Practice Address - State:MD
Practice Address - Zip Code:21853
Practice Address - Country:US
Practice Address - Phone:410-651-9852
Practice Address - Fax:410-651-1279
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15821183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS118Medicare PIN