Provider Demographics
NPI:1063024628
Name:NORDIN, JAMES LARRY
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LARRY
Last Name:NORDIN
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 1:339 MCCLUER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-5412
Mailing Address - Country:US
Mailing Address - Phone:601-955-6636
Mailing Address - Fax:601-833-9626
Practice Address - Street 1:719 BROOKWAY BLVD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2639
Practice Address - Country:US
Practice Address - Phone:601-833-8509
Practice Address - Fax:601-833-9626
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE06337183500000X
MSE-006337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist