Provider Demographics
NPI:1902168453
Name:KING, JAYNE L (RPH)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:L
Last Name:KING
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-1409
Mailing Address - Country:US
Mailing Address - Phone:765-742-3462
Mailing Address - Fax:
Practice Address - Street 1:3530 STATE ROAD 38 E
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5121
Practice Address - Country:US
Practice Address - Phone:765-448-6592
Practice Address - Fax:765-448-6168
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015535A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist