Provider Demographics
NPI:1265705446
Name:ROGERS, JERRY D (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:ROGERS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WALL ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35904-1938
Mailing Address - Country:US
Mailing Address - Phone:256-547-1221
Mailing Address - Fax:256-547-1299
Practice Address - Street 1:300 WALL ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35904-1938
Practice Address - Country:US
Practice Address - Phone:256-547-1221
Practice Address - Fax:256-547-1299
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL105633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100001483Medicaid
0799180001Medicare NSC
AL0112110Medicare UPIN