Basic Information
| Provider Information | |||||||||
| NPI: | 1306181755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAVIS | ||||||||
| FirstName: | JENNY-REBECCA | ||||||||
| MiddleName: | FAITH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 413 LILLY RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604935369 | ||||||||
| FaxNumber: | 3604937154 | ||||||||
| Practice Location | |||||||||
| Address1: | 413 LILLY RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604935369 | ||||||||
| FaxNumber: | 3604937154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2012 | ||||||||
| LastUpdateDate: | 08/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PH60213057 | WA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.