Provider Demographics
NPI:1770129215
Name:TAVERNIER, JAMIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:TAVERNIER
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 1:530 S INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-1712
Mailing Address - Country:US
Mailing Address - Phone:317-831-9416
Mailing Address - Fax:317-831-9418
Practice Address - Street 1:530 S INDIANA ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1712
Practice Address - Country:US
Practice Address - Phone:317-831-9416
Practice Address - Fax:317-831-9418
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023767A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist