Provider Demographics
NPI:1982239257
Name:JAHNKE, COREY W (RPH)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:W
Last Name:JAHNKE
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 1:3509 CUMMINGS AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7385
Mailing Address - Country:US
Mailing Address - Phone:715-651-6908
Mailing Address - Fax:
Practice Address - Street 1:535 E DIVISION AVE
Practice Address - Street 2:
Practice Address - City:BARRON
Practice Address - State:WI
Practice Address - Zip Code:54812-1171
Practice Address - Country:US
Practice Address - Phone:715-637-0991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11468-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist