MEDICARE: JERROLD WALKER SMITH RPH

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	10165	LA

General Provider Information

NPI Number	:	1144503475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERROLD WALKER SMITH RPH

Provider Business Mailing Address
First Line	:	366 SAM HOUSTON JONES PKWY
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-5602
Country	:	US
Telephone Number	:	337-855-1341
Fax Number	:	337-855-4273

Provider Business Practice Location Address
First Line	:	366 SAM HOUSTON JONES PKWY
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70611-5602
Country	:	US
Telephone Number	:	337-855-1341
Fax Number	:	337-855-4273

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

Provider Enumeration Date	:	09/22/2011
Last Update Date	:	09/22/2011

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