Provider Demographics
NPI:1306121629
Name:MILLER, JERRY ROBERT (RPH)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:ROBERT
Last Name:MILLER
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 1:1876 RUDGATE DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8410
Mailing Address - Country:US
Mailing Address - Phone:317-272-2716
Mailing Address - Fax:
Practice Address - Street 1:7975 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7975
Practice Address - Country:US
Practice Address - Phone:317-272-5563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26015212183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist