Provider Demographics
NPI:1538454061
Name:RODGERS, JERRY II
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:RODGERS
Suffix:II
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 1:7378 FAYETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44215-9812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7378 FAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:CHIPPEWA LAKE
Practice Address - State:OH
Practice Address - Zip Code:44215-9812
Practice Address - Country:US
Practice Address - Phone:330-769-4554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03223315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist