Provider Demographics
NPI:1508234238
Name:DEOM, GERALD (RPH)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:DEOM
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 1:8820 RINEYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RINEYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40162-9741
Mailing Address - Country:US
Mailing Address - Phone:270-268-0259
Mailing Address - Fax:
Practice Address - Street 1:8820 RINEYVILLE RD
Practice Address - Street 2:
Practice Address - City:RINEYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40162-9741
Practice Address - Country:US
Practice Address - Phone:270-268-0259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY006077OtherKENTUCKY PHARMACIST LICENSE