MEDICARE: JERRY RODGERS II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	03223315	OH

General Provider Information

NPI Number	:	1538454061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY RODGERS II

Provider Business Mailing Address
First Line	:	7378 FAYETTE BLVD
Second Line	:
City	:	CHIPPEWA LAKE
State	:	OH
Zip	:	44215-9812
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7378 FAYETTE BLVD
Second Line	:
City	:	CHIPPEWA LAKE
State	:	OH
Zip	:	44215-9812
Country	:	US
Telephone Number	:	330-769-4554
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2011
Last Update Date	:	06/13/2011

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