Provider Demographics
NPI:1548669450
Name:PENDERGRASS, JESSICA ADRIAN (RPH)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ADRIAN
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:ADRIAN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1614 GLENN BLVD SW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-3522
Mailing Address - Country:US
Mailing Address - Phone:256-845-3402
Mailing Address - Fax:256-845-3289
Practice Address - Street 1:1614 GLENN BLVD SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968-3522
Practice Address - Country:US
Practice Address - Phone:256-845-3402
Practice Address - Fax:256-845-3289
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist