MEDICARE: MR. JERRY CURTIS BAILEY R.PH

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	03-3-17124	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30-3-17124	OTHER	OH	PHARMACIST

General Provider Information

NPI Number	:	1902895261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY CURTIS BAILEY R.PH

Provider Business Mailing Address
First Line	:	3013 CLEVELAND AVE SW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44707-3625
Country	:	US
Telephone Number	:	330-484-9310
Fax Number	:	330-484-9318

Provider Business Practice Location Address
First Line	:	3013 CLEVELAND AVE SW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44707-3625
Country	:	US
Telephone Number	:	330-484-9310
Fax Number	:	330-484-9318

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

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	07/08/2007

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