Provider Demographics
NPI:1346648268
Name:MULLINS, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:MULLINS
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 325
Mailing Address - Street 2:
Mailing Address - City:DORTON
Mailing Address - State:KY
Mailing Address - Zip Code:41520-0325
Mailing Address - Country:US
Mailing Address - Phone:606-794-8740
Mailing Address - Fax:
Practice Address - Street 1:121 BOONE RIDGE DR, SUITE 1006
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615
Practice Address - Country:US
Practice Address - Phone:423-282-0520
Practice Address - Fax:423-282-0520
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000038748183500000X
VA0202213552183500000X
NC24684183500000X
KY017462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist