Basic Information
| Provider Information | |||||||||
| NPI: | 1053047373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THEIS | ||||||||
| FirstName: | JEROD | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 518 LARIMER ST | ||||||||
| Address2: | |||||||||
| City: | PRATT | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671241315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6203880342 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3200 PLAZA EAST DR | ||||||||
| Address2: | |||||||||
| City: | HUTCHINSON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 675021607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206637628 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2022 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 1-106989 | KS | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.