Provider Demographics
NPI:1679889570
Name:FANECK, JEFFREY (PHARMD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:FANECK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 CHERRIE CIR
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-3415
Mailing Address - Country:US
Mailing Address - Phone:610-308-4033
Mailing Address - Fax:
Practice Address - Street 1:3601 MIDVALE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1712
Practice Address - Country:US
Practice Address - Phone:215-842-2950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP442250183500000X
MEPR5192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist