Provider Demographics
NPI:1346201142
Name:MASSEY, JIMMY DERRELL
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:DERRELL
Last Name:MASSEY
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:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:SECTION
Mailing Address - State:AL
Mailing Address - Zip Code:35771-0029
Mailing Address - Country:US
Mailing Address - Phone:256-228-6443
Mailing Address - Fax:
Practice Address - Street 1:5337 TAMMY LITTLE DR
Practice Address - Street 2:
Practice Address - City:SECTION
Practice Address - State:AL
Practice Address - Zip Code:35771-7206
Practice Address - Country:US
Practice Address - Phone:256-228-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10177183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist