Provider Demographics
NPI:1174875207
Name:PELAGE, JOANN (PHARMD)
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:PELAGE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 S GENERAL BRUCE DR BLDG A100
Mailing Address - Street 2:T-2278
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-5133
Mailing Address - Country:US
Mailing Address - Phone:254-295-1058
Mailing Address - Fax:
Practice Address - Street 1:3550 S GENERAL BRUCE DR BLDG A100
Practice Address - Street 2:T-2278
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-5133
Practice Address - Country:US
Practice Address - Phone:254-295-1058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-13
Last Update Date:2012-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52425183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist