Provider Demographics
NPI:1780195792
Name:MARSHALL, JEFFREY LIND (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:LIND
Last Name:MARSHALL
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 2407
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-2407
Mailing Address - Country:US
Mailing Address - Phone:909-338-1875
Mailing Address - Fax:909-338-1876
Practice Address - Street 1:580 FOREST SHADE RD
Practice Address - Street 2:SUITE 7
Practice Address - City:CRESTLINE
Practice Address - State:CA
Practice Address - Zip Code:92325
Practice Address - Country:US
Practice Address - Phone:909-338-1875
Practice Address - Fax:909-338-1876
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH33151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295869733Medicaid