Provider Demographics
NPI:1578993952
Name:MO, JEROME (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:MO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 VIA VERDE AVE.
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773
Mailing Address - Country:US
Mailing Address - Phone:909-599-3444
Mailing Address - Fax:323-277-9550
Practice Address - Street 1:1152 VIA VERDE AVE.
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773
Practice Address - Country:US
Practice Address - Phone:909-599-3444
Practice Address - Fax:909-599-6627
Is Sole Proprietor?:No
Enumeration Date:2013-11-20
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist