Provider Demographics
NPI:1770709313
Name:GERDES, KERRY W (RPH)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:W
Last Name:GERDES
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 1:1960 BRIDGEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-3008
Mailing Address - Country:US
Mailing Address - Phone:440-599-8569
Mailing Address - Fax:
Practice Address - Street 1:245 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030-2653
Practice Address - Country:US
Practice Address - Phone:440-593-2578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03213262183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist