Provider Demographics
NPI:1568767689
Name:WHITACRE, JERRY DAVID (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:DAVID
Last Name:WHITACRE
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 1:5949 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-3752
Mailing Address - Country:US
Mailing Address - Phone:562-496-1851
Mailing Address - Fax:562-496-1251
Practice Address - Street 1:5949 E SPRING ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-3752
Practice Address - Country:US
Practice Address - Phone:562-496-1851
Practice Address - Fax:562-496-1251
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22685183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist