Provider Demographics
NPI:1659411601
Name:MCCUAN, JERRY D (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:D
Last Name:MCCUAN
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:PO BOX 759
Mailing Address - Street 2:821 MAIN ST
Mailing Address - City:RALLS
Mailing Address - State:TX
Mailing Address - Zip Code:79357-0759
Mailing Address - Country:US
Mailing Address - Phone:806-253-2256
Mailing Address - Fax:806-253-2401
Practice Address - Street 1:821 MAIN ST
Practice Address - Street 2:
Practice Address - City:RALLS
Practice Address - State:TX
Practice Address - Zip Code:79357
Practice Address - Country:US
Practice Address - Phone:806-253-2256
Practice Address - Fax:806-253-2401
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2008-02-19
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2008-02-19
Provider Licenses
StateLicense IDTaxonomies
TX17541183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140384Medicaid