Provider Demographics
NPI:1205312204
Name:CHAPMAN, JERRY RICHARD
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:RICHARD
Last Name:CHAPMAN
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 1:1589 SIERRA VISTA PLZ
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-2040
Mailing Address - Country:US
Mailing Address - Phone:314-355-8314
Mailing Address - Fax:
Practice Address - Street 1:1589 SIERRA VISTA PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-2040
Practice Address - Country:US
Practice Address - Phone:314-355-8314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300559183500000X
MO2017029978183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist