Provider Demographics
NPI:1952906877
Name:DEVAULT, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:DEVAULT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46065-9403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:366 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46065-9403
Practice Address - Country:US
Practice Address - Phone:765-379-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019562A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist