Provider Demographics
NPI:1609956200
Name:PARKS, JESSE T (RPH)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:T
Last Name:PARKS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SOUTH MAIN
Mailing Address - Street 2:STE 2
Mailing Address - City:CONRAD
Mailing Address - State:MT
Mailing Address - Zip Code:59425
Mailing Address - Country:US
Mailing Address - Phone:406-278-3267
Mailing Address - Fax:406-278-3851
Practice Address - Street 1:600 SOUTH MAIN
Practice Address - Street 2:STE 2
Practice Address - City:CONRAD
Practice Address - State:MT
Practice Address - Zip Code:59425
Practice Address - Country:US
Practice Address - Phone:406-278-3267
Practice Address - Fax:406-278-3851
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT2704535Medicaid