Provider Demographics
NPI:1174249122
Name:HARRIES, JAKE MICHAEL (RPH)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:MICHAEL
Last Name:HARRIES
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:PO BOX 892920
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-2920
Mailing Address - Country:US
Mailing Address - Phone:951-719-9477
Mailing Address - Fax:
Practice Address - Street 1:14220 SCHLEISMAN RD
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-4020
Practice Address - Country:US
Practice Address - Phone:951-340-0875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist