Provider Demographics
NPI:1003448895
Name:ARCHULETA, JERRY PATRICK (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:PATRICK
Last Name:ARCHULETA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2395
Mailing Address - Country:US
Mailing Address - Phone:719-589-3165
Mailing Address - Fax:719-589-3270
Practice Address - Street 1:1203 MAIN ST
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2395
Practice Address - Country:US
Practice Address - Phone:719-589-3165
Practice Address - Fax:719-589-3270
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11784183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist