Provider Demographics
NPI:1487664637
Name:GARRISON, JIMMY L (BSRPH/PD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:L
Last Name:GARRISON
Suffix:
Gender:M
Credentials:BSRPH/PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 CHALMERS DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5615
Mailing Address - Country:US
Mailing Address - Phone:636-532-1145
Mailing Address - Fax:
Practice Address - Street 1:2709 HIGH RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:HIGH RIDGE
Practice Address - State:MO
Practice Address - Zip Code:63049-2202
Practice Address - Country:US
Practice Address - Phone:636-677-3900
Practice Address - Fax:636-677-7795
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO027630183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist