Provider Demographics
NPI:1437178365
Name:COLE, JERRY DANIEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:DANIEL
Last Name:COLE
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 1:488 HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:WRIGHTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:92397
Mailing Address - Country:US
Mailing Address - Phone:760-249-6505
Mailing Address - Fax:
Practice Address - Street 1:16854 IVY AVE
Practice Address - Street 2:SUITE C
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:909-356-0110
Practice Address - Fax:909-356-1024
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27438183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0596354OtherNABP NUMBER
CAPHA352970Medicaid
CAPHA352970Medicaid