Provider Demographics
NPI:1790883619
Name:RICH, JERRY STEVE (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:STEVE
Last Name:RICH
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 1:2415 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-9261
Mailing Address - Country:US
Mailing Address - Phone:541-580-5594
Mailing Address - Fax:
Practice Address - Street 1:2415 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-9261
Practice Address - Country:US
Practice Address - Phone:541-580-5594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26570183500000X
LA10810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist