Provider Demographics
NPI:1477962934
Name:PEROUTKA, JULI
Entity Type:Individual
Prefix:
First Name:JULI
Middle Name:
Last Name:PEROUTKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 TALON DR
Mailing Address - Street 2:
Mailing Address - City:SHINGLE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95682-9739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4300 MISSOURI FLAT RD
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-6811
Practice Address - Country:US
Practice Address - Phone:530-621-3447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-09
Last Update Date:2014-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist