Provider Demographics
NPI:1730722117
Name:ERICSON, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ERICSON
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:PO BOX 3266
Mailing Address - Street 2:
Mailing Address - City:WINGATE
Mailing Address - State:NC
Mailing Address - Zip Code:28174-3266
Mailing Address - Country:US
Mailing Address - Phone:508-930-4617
Mailing Address - Fax:
Practice Address - Street 1:6713 E MARSHVILLE BLVD
Practice Address - Street 2:
Practice Address - City:MARSHVILLE
Practice Address - State:NC
Practice Address - Zip Code:28103-1192
Practice Address - Country:US
Practice Address - Phone:704-624-2156
Practice Address - Fax:704-624-3765
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist