Provider Demographics
NPI:1033428578
Name:CROWLEY REVERE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CROWLEY REVERE
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 1:1039 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MARKS
Mailing Address - State:MS
Mailing Address - Zip Code:38646-1808
Mailing Address - Country:US
Mailing Address - Phone:662-326-8609
Mailing Address - Fax:662-326-3449
Practice Address - Street 1:1039 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-1808
Practice Address - Country:US
Practice Address - Phone:662-326-8609
Practice Address - Fax:662-326-3449
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-010718183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist