Provider Demographics
NPI:1285071654
Name:JEFFERSON, ALDA
Entity type:Individual
Prefix:
First Name:ALDA
Middle Name:
Last Name:JEFFERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 E SHELBY DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7124
Mailing Address - Country:US
Mailing Address - Phone:901-346-3336
Mailing Address - Fax:901-346-6613
Practice Address - Street 1:4075 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-8302
Practice Address - Country:US
Practice Address - Phone:901-795-7335
Practice Address - Fax:901-366-3949
Is Sole Proprietor?:No
Enumeration Date:2013-05-26
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-12526183500000X
TN36638183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist