Provider Demographics
NPI:1750782314
Name:VANTRESS, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:VANTRESS
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 1:725 S WAHANNA RD
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97138-7735
Mailing Address - Country:US
Mailing Address - Phone:503-717-7380
Mailing Address - Fax:
Practice Address - Street 1:725 S WAHANNA RD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-7735
Practice Address - Country:US
Practice Address - Phone:503-717-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0014315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist