Healthcare Provider Details

I. General information

NPI: 1538454061
Provider Name (Legal Business Name): JERRY RODGERS II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7378 FAYETTE BLVD
CHIPPEWA LAKE OH
44215-9812
US

IV. Provider business mailing address

7378 FAYETTE BLVD
CHIPPEWA LAKE OH
44215-9812
US

V. Phone/Fax

Practice location:
  • Phone: 330-769-4554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03223315
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: