Provider Demographics
NPI:1962700435
Name:EVERETT, JIM
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:EVERETT
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:P.O. BOX 527
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:TX
Mailing Address - Zip Code:76950-0527
Mailing Address - Country:US
Mailing Address - Phone:325-387-2541
Mailing Address - Fax:325-387-5423
Practice Address - Street 1:417 HIGHWAY 277 N
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:TX
Practice Address - Zip Code:76950-2204
Practice Address - Country:US
Practice Address - Phone:325-387-2541
Practice Address - Fax:325-387-5423
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18546183500000X
TX231823336C0003X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0358420002Medicare NSC
0358420001Medicare NSC