Provider Demographics
NPI:1235416157
Name:SIMMONS, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:SIMMONS
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 1:4880 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:HILLTOP
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1950
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4880 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:HILLTOP
Practice Address - State:MN
Practice Address - Zip Code:55421-1950
Practice Address - Country:US
Practice Address - Phone:763-571-7195
Practice Address - Fax:763-571-9340
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-06
Last Update Date:2011-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116697183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist