Provider Demographics
NPI:1063849578
Name:GLOVER PRIMARY CARE CLINIC
Entity Type:Organization
Organization Name:GLOVER PRIMARY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLOVERJACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:662-316-1334
Mailing Address - Street 1:403 NW DEPOT ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:MS
Mailing Address - Zip Code:39063-3705
Mailing Address - Country:US
Mailing Address - Phone:662-316-1334
Mailing Address - Fax:
Practice Address - Street 1:403 NW DEPOT ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:MS
Practice Address - Zip Code:39063-3705
Practice Address - Country:US
Practice Address - Phone:662-316-1334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-28
Last Update Date:2013-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR856333261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR856333OtherNURSE LICENSE