Provider Demographics
NPI:1790297869
Name:MCDONALD, JESSE MATTHEW (PHARMD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:MATTHEW
Last Name:MCDONALD
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 1:6140 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3821
Mailing Address - Country:US
Mailing Address - Phone:440-204-4307
Mailing Address - Fax:440-204-4135
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3821
Practice Address - Country:US
Practice Address - Phone:440-204-4307
Practice Address - Fax:440-204-4135
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03234036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03234036OtherBOARD OF PHARMACY - PHARMACIST LICENSE