Provider Demographics
NPI:1194035535
Name:ARQUIETTE, JERED MICHAEL
Entity Type:Individual
Prefix:
First Name:JERED
Middle Name:MICHAEL
Last Name:ARQUIETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1020
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-1020
Mailing Address - Country:US
Mailing Address - Phone:209-468-6000
Mailing Address - Fax:209-468-7042
Practice Address - Street 1:500 W. HOSPITAL RD.
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-8898
Practice Address - Country:US
Practice Address - Phone:209-468-6000
Practice Address - Fax:209-468-7042
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61877183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist