Provider Demographics
NPI:1851669675
Name:JENKINS, REGINALD KEITH (RPH)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:KEITH
Last Name:JENKINS
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 1:1043 WALT WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-5617
Mailing Address - Country:US
Mailing Address - Phone:863-255-5609
Mailing Address - Fax:
Practice Address - Street 1:1043 WALT WILLIAMS ROAD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809
Practice Address - Country:US
Practice Address - Phone:863-255-5609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS00017559183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist