Provider Demographics
NPI:1114522265
Name:SISEMORE, JERALD GRANT JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:GRANT
Last Name:SISEMORE
Suffix:JR
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 1:20601 FM 1431
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-4505
Mailing Address - Country:US
Mailing Address - Phone:512-267-8010
Mailing Address - Fax:512-267-8016
Practice Address - Street 1:20601 FM 1431
Practice Address - Street 2:
Practice Address - City:LAGO VISTA
Practice Address - State:TX
Practice Address - Zip Code:78645-4505
Practice Address - Country:US
Practice Address - Phone:512-267-8010
Practice Address - Fax:512-267-8016
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43621183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist