Provider Demographics
NPI:1245315225
Name:JERKINS, KEN M (RPH)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:M
Last Name:JERKINS
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 1:101 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-3435
Mailing Address - Country:US
Mailing Address - Phone:561-585-4677
Mailing Address - Fax:561-588-8562
Practice Address - Street 1:101 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-3435
Practice Address - Country:US
Practice Address - Phone:561-585-4677
Practice Address - Fax:561-588-8562
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11405183500000X
TN399183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist