Provider Demographics
NPI:1972194827
Name:JARA, LOUIS ANTHONY (RPH)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:ANTHONY
Last Name:JARA
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 1:495 E 3RD ST APT G11
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-4984
Mailing Address - Country:US
Mailing Address - Phone:323-286-9047
Mailing Address - Fax:
Practice Address - Street 1:33499 YUCAIPA BLVD
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2064
Practice Address - Country:US
Practice Address - Phone:909-797-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83467183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty