Provider Demographics
NPI:1568981058
Name:SKEENES, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:SKEENES
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 1:1563 SAND PLANT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-6120
Mailing Address - Country:US
Mailing Address - Phone:304-756-2181
Mailing Address - Fax:304-756-2796
Practice Address - Street 1:1563 SAND PLANT RD
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-6120
Practice Address - Country:US
Practice Address - Phone:304-756-2181
Practice Address - Fax:304-756-2796
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2641183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist