Provider Demographics
NPI:1891390753
Name:STUART, JERRY ALLAN
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:ALLAN
Last Name:STUART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-3739
Mailing Address - Country:US
Mailing Address - Phone:281-338-4010
Mailing Address - Fax:
Practice Address - Street 1:102 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-3739
Practice Address - Country:US
Practice Address - Phone:281-338-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist