Provider Demographics
NPI:1871902304
Name:KRUCKEMEYER, JEREMIAH
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:KRUCKEMEYER
Suffix:
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 1:135 CREEKSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-6248
Mailing Address - Country:US
Mailing Address - Phone:830-608-3281
Mailing Address - Fax:
Practice Address - Street 1:135 CREEKSIDE WAY
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-6248
Practice Address - Country:US
Practice Address - Phone:830-608-3281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55332183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist