Provider Demographics
NPI:1144502972
Name:KUNTZ, JERRY WAYNE (RPH)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:KUNTZ
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 1:10870 OVERSEAS HWY
Mailing Address - Street 2:
Mailing Address - City:MARATHON
Mailing Address - State:FL
Mailing Address - Zip Code:33050-3455
Mailing Address - Country:US
Mailing Address - Phone:305-743-6929
Mailing Address - Fax:305-743-9658
Practice Address - Street 1:10870 OVERSEAS HWY
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:FL
Practice Address - Zip Code:33050-3455
Practice Address - Country:US
Practice Address - Phone:305-743-6929
Practice Address - Fax:305-743-9658
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS22459183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist