Provider Demographics
NPI:1770129843
Name:LANGHAM, JEFF RUSSELL (RPH)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:RUSSELL
Last Name:LANGHAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 S MERRIFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2807
Mailing Address - Country:US
Mailing Address - Phone:574-256-7522
Mailing Address - Fax:574-256-7524
Practice Address - Street 1:906 S MERRIFIELD AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-2807
Practice Address - Country:US
Practice Address - Phone:574-256-7522
Practice Address - Fax:574-256-7524
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26091666A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist