Healthcare Provider Details

I. General information

NPI: 1528368024
Provider Name (Legal Business Name): JEFFERY ROBERT PROCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2010
Last Update Date: 08/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2048 E AVENIDA DE LOS ARBOLES
THOUSAND OAKS CA
91362-1356
US

IV. Provider business mailing address

2048 E AVENIDA DE LOS ARBOLES
THOUSAND OAKS CA
91362-1356
US

V. Phone/Fax

Practice location:
  • Phone: 805-492-3511
  • Fax:
Mailing address:
  • Phone: 805-492-3511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number63884
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: