Provider Demographics
NPI:1528368024
Name:PROCTOR, JEFFERY ROBERT
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ROBERT
Last Name:PROCTOR
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 1:2048 E AVENIDA DE LOS ARBOLES
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-1356
Mailing Address - Country:US
Mailing Address - Phone:805-492-3511
Mailing Address - Fax:
Practice Address - Street 1:2048 E AVENIDA DE LOS ARBOLES
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-1356
Practice Address - Country:US
Practice Address - Phone:805-492-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-30
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63884183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist