Provider Demographics
NPI:1497498372
Name:PRUITT, JESSE NATHANIEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:NATHANIEL
Last Name:PRUITT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 AUTUMN RD STE 275
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3745
Mailing Address - Country:US
Mailing Address - Phone:501-224-3499
Mailing Address - Fax:501-224-1140
Practice Address - Street 1:904 AUTUMN RD STE 275
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3745
Practice Address - Country:US
Practice Address - Phone:501-224-3499
Practice Address - Fax:501-224-3499
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD15030183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPD15030OtherAR PHARMACIST LICENSE