Provider Demographics
NPI:1386196186
Name:JEROME, CLEVENS
Entity Type:Individual
Prefix:
First Name:CLEVENS
Middle Name:
Last Name:JEROME
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 1:10728 NW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33168-4301
Mailing Address - Country:US
Mailing Address - Phone:786-350-8123
Mailing Address - Fax:
Practice Address - Street 1:400 HIALEAH DR
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-5347
Practice Address - Country:US
Practice Address - Phone:305-884-8774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL55793183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist