Provider Demographics
NPI:1831734482
Name:MARCOUX, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MARCOUX
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 1:36 TRIBECA CT
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 STATE ROAD 13
Practice Address - Street 2:WALMART PHARMACY
Practice Address - City:FRUIT COVE
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:904-417-9088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34222183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist