Provider Demographics
NPI:1164287645
Name:GOSSETT, JACEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACEY
Middle Name:
Last Name:GOSSETT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 COUNTY ROAD 378
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-3731
Mailing Address - Country:US
Mailing Address - Phone:662-934-8403
Mailing Address - Fax:
Practice Address - Street 1:1100 BELK BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5242
Practice Address - Country:US
Practice Address - Phone:662-934-8403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE100832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist