=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902951411
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEROMY LOVE KLOSS PHARM.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 483 W SEED FARM RD
-----------------------------------------------------
City | SACATON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-528-1303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1194 E DAISY WAY
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85243-6175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-528-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 15496
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------