Provider Demographics
NPI:1801200845
Name:DE BRUIN, JERRY (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:DE BRUIN
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 1:9220 N THORNYDALE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-5025
Mailing Address - Country:US
Mailing Address - Phone:520-579-9991
Mailing Address - Fax:
Practice Address - Street 1:9220 N THORNYDALE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85742-5025
Practice Address - Country:US
Practice Address - Phone:520-579-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist