Healthcare Provider Details

I. General information

NPI: 1326324997
Provider Name (Legal Business Name): SHANE LEE JEROMINSKI PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78218 VARNER RD
PALM DESERT CA
92211-4134
US

IV. Provider business mailing address

78218 VARNER RD
PALM DESERT CA
92211-4134
US

V. Phone/Fax

Practice location:
  • Phone: 760-200-4382
  • Fax: 760-772-0825
Mailing address:
  • Phone: 760-200-4382
  • Fax: 760-772-0825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: