Provider Demographics
NPI:1427367390
Name:OSWALT, JEFFREY
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:OSWALT
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 1:12967 ARBOR DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6091
Mailing Address - Country:US
Mailing Address - Phone:901-351-1745
Mailing Address - Fax:662-510-2197
Practice Address - Street 1:8831 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-2203
Practice Address - Country:US
Practice Address - Phone:662-655-1437
Practice Address - Fax:662-510-2197
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08674183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist