Provider Demographics
NPI:1033798129
Name:BOBO, JONATHAN TYLER (PHARMD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TYLER
Last Name:BOBO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1132
Mailing Address - Country:US
Mailing Address - Phone:662-426-3629
Mailing Address - Fax:662-423-3620
Practice Address - Street 1:1519 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1132
Practice Address - Country:US
Practice Address - Phone:662-426-3629
Practice Address - Fax:662-423-3620
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE15090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist