MEDICARE: JOHN JEROME HERNANDEZ

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	9110	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9110	OTHER	LA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1720119761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN JEROME HERNANDEZ

Provider Business Mailing Address
First Line	:	408 LEBESQUE RD
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70507-5106
Country	:	US
Telephone Number	:	337-232-7127
Fax Number	:

Provider Business Practice Location Address
First Line	:	9021 CAMERON ST
Second Line	:
City	:	DUSON
State	:	LA
Zip	:	70529
Country	:	US
Telephone Number	:	337-873-6182
Fax Number	:

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

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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