Provider Demographics
NPI:1285669150
Name:JENKINS, LARRY CARLTON
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CARLTON
Last Name:JENKINS
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 1:912 HIGHWAY 15
Mailing Address - Street 2:PO BOX 128
Mailing Address - City:STRINGER
Mailing Address - State:MS
Mailing Address - Zip Code:39481-0128
Mailing Address - Country:US
Mailing Address - Phone:601-649-4418
Mailing Address - Fax:601-649-4487
Practice Address - Street 1:912 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:STRINGER
Practice Address - State:MS
Practice Address - Zip Code:39481-4230
Practice Address - Country:US
Practice Address - Phone:601-649-4418
Practice Address - Fax:601-649-4487
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05068/11.1332B00000X
MS05321/02.53336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440829Medicaid
MS00330648Medicaid
MS1700073905OtherMEDICARE NPI
MS3939790001Medicare NSC