Provider Demographics
NPI:1962557025
Name:POE, JIMMY R (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:R
Last Name:POE
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 HUMMING BIRD DR
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-2623
Mailing Address - Country:US
Mailing Address - Phone:662-887-4533
Mailing Address - Fax:662-887-4572
Practice Address - Street 1:124 E BAKER ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2451
Practice Address - Country:US
Practice Address - Phone:662-887-4533
Practice Address - Fax:662-887-4572
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE5898183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist