Provider Demographics
NPI:1053047373
Name:THEIS, JEROD WILLIAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEROD
Middle Name:WILLIAM
Last Name:THEIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 LARIMER ST
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-1315
Mailing Address - Country:US
Mailing Address - Phone:620-388-0342
Mailing Address - Fax:
Practice Address - Street 1:3200 PLAZA EAST DR
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1607
Practice Address - Country:US
Practice Address - Phone:620-663-7628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-106989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist