Provider Demographics
NPI:1154647287
Name:LANE, JIMMY GREGORY
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:GREGORY
Last Name:LANE
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 1:1369 B GEORGE WALLACE HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35654
Mailing Address - Country:US
Mailing Address - Phone:256-332-4021
Mailing Address - Fax:256-332-4026
Practice Address - Street 1:1369 B GEORGE WALLACE HIGHWAY
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35654
Practice Address - Country:US
Practice Address - Phone:256-332-4021
Practice Address - Fax:256-332-4026
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7848183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist