Provider Demographics
NPI:1740564343
Name:TUCKER, JERRY ALTON JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:ALTON
Last Name:TUCKER
Suffix:JR
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 1:1505 CRESCENT MOON CV
Mailing Address - Street 2:
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410-8579
Mailing Address - Country:US
Mailing Address - Phone:843-906-6080
Mailing Address - Fax:843-460-2020
Practice Address - Street 1:3050 ASHLEY TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5664
Practice Address - Country:US
Practice Address - Phone:843-460-2002
Practice Address - Fax:843-460-2020
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-01
Last Update Date:2011-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9166183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist