Provider Demographics
NPI:1780897421
Name:MENDUM, JASSICA ANDREA (RPH, CPH)
Entity type:Individual
Prefix:MISS
First Name:JASSICA
Middle Name:ANDREA
Last Name:MENDUM
Suffix:
Gender:F
Credentials:RPH, CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-6991
Mailing Address - Country:US
Mailing Address - Phone:352-867-5565
Mailing Address - Fax:
Practice Address - Street 1:2131 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-6991
Practice Address - Country:US
Practice Address - Phone:352-867-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 35722183500000X
FLPU 5761183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist