Provider Demographics
NPI:1235692039
Name:BERNDT, JERRY S (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:S
Last Name:BERNDT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4508 AUBURN WAY N STE A104
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-1381
Mailing Address - Country:US
Mailing Address - Phone:253-373-9944
Mailing Address - Fax:253-269-9791
Practice Address - Street 1:4508 AUBURN WAY N
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-1381
Practice Address - Country:US
Practice Address - Phone:253-373-9944
Practice Address - Fax:253-269-9791
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00011513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist