Basic Information
| Provider Information | |||||||||
| NPI: | 1639335532 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019683066 | ||||||||
| FaxNumber: | 6019603319 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019681000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2008 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | E-06981 | MS | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.