Provider Demographics
NPI:1639471618
Name:KLEIN, JERRY BRADLEY (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:BRADLEY
Last Name:KLEIN
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 1:475 M ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-4129
Mailing Address - Country:US
Mailing Address - Phone:707-465-3663
Mailing Address - Fax:
Practice Address - Street 1:475 M ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-4129
Practice Address - Country:US
Practice Address - Phone:707-465-3663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-24
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33188183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist