Provider Demographics
NPI:1932447794
Name:STEPHENS, JILL MCCALLUM (RPH)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MCCALLUM
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2663 HIGHWAY 349 S
Mailing Address - Street 2:
Mailing Address - City:POTTS CAMP
Mailing Address - State:MS
Mailing Address - Zip Code:38659-9267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 E VAN DORN AVE
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-3025
Practice Address - Country:US
Practice Address - Phone:662-252-2321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08916183500000X
TN0000010219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist