Provider Demographics
NPI:1427696996
Name:JESSUP, GARY WAYNE
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:JESSUP
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 1:1203 US HIGHWAY 380
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:76426-2087
Mailing Address - Country:US
Mailing Address - Phone:940-683-1510
Mailing Address - Fax:866-248-6798
Practice Address - Street 1:1203 US HIGHWAY 380
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-2087
Practice Address - Country:US
Practice Address - Phone:940-683-1510
Practice Address - Fax:866-248-6798
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX26112OtherTEXAS BOARD OF PHARMACY