Provider Demographics
NPI:1588604334
Name:JEFFERSON HEALTH SYSTEM PHARMACY
Entity Type:Organization
Organization Name:JEFFERSON HEALTH SYSTEM PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-918-2352
Mailing Address - Street 1:601 WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35206-1300
Mailing Address - Country:US
Mailing Address - Phone:205-838-4310
Mailing Address - Fax:
Practice Address - Street 1:2817 30TH AVE N
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35207-4541
Practice Address - Country:US
Practice Address - Phone:205-521-6855
Practice Address - Fax:205-521-6854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL140009333600000X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100003671Medicaid
0124507OtherOTHER ID NUMBER-COMMERCIAL NUMBER