Active NPI
Jackleen Fan
- Pharmacist
- Evans, GA
National Provider Identifier
1407337306
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- RPH030830
- Practice address
- 4310 Washington Rd
Evans, GA 30809-3957 - Phone
- (706) 860-4179
- NPI assigned
- Aug 28, 2018
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | RPH030830 | GA | Primary |
Addresses
Primary practice location
4310 Washington Rd
Evans, GA 30809-3957
Mailing address
372 Collins Glen CT
Lawrenceville, GA 30043-6848
Phone (706) 773-9237
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RPH030830 | GA | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Walgreen Co | Past | Accepting new patients | |
| Walgreen Co | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Pharmacy
- Evans, GA
- NPI 1790925691
-
- Pharmacy
- Longview, TX
- NPI 1629956545
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1535414400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1535414400000",
"number": "1407337306",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "372 COLLINS GLEN CT",
"city": "LAWRENCEVILLE",
"state": "GA",
"postal_code": "300436848",
"telephone_number": "706-773-9237"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4310 WASHINGTON RD",
"city": "EVANS",
"state": "GA",
"postal_code": "308093957",
"telephone_number": "706-860-4179"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FAN",
"first_name": "JACKLEEN",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2018-08-28",
"last_updated": "2018-08-28",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "GA",
"license": "RPH030830",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Evans, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.