Provider Demographics
NPI:1720391485
Name:GOTTBE, JERRY (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:GOTTBE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5324 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-2144
Mailing Address - Country:US
Mailing Address - Phone:602-732-3384
Mailing Address - Fax:
Practice Address - Street 1:5324 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2144
Practice Address - Country:US
Practice Address - Phone:602-732-3384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS010987183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist