Provider Demographics
NPI:1326328865
Name:WILLIAMS, JIMMY
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:WILLIAMS
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 1:110600 S 4750 RD
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-5986
Mailing Address - Country:US
Mailing Address - Phone:918-759-8128
Mailing Address - Fax:
Practice Address - Street 1:323 HIGHWAY 64 W
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:AR
Practice Address - Zip Code:72921-3301
Practice Address - Country:US
Practice Address - Phone:479-632-9080
Practice Address - Fax:479-632-9086
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14731183500000X
ARAR11454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist