Provider Demographics
NPI:1619050150
Name:SANDERS, JACK LARRY (R PH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:LARRY
Last Name:SANDERS
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8324
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-8324
Mailing Address - Country:US
Mailing Address - Phone:601-729-4407
Mailing Address - Fax:601-428-0689
Practice Address - Street 1:3160 AUDUBON DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440
Practice Address - Country:US
Practice Address - Phone:601-428-0688
Practice Address - Fax:601-428-0689
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-06744183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE-06744OtherSTATE LICENSE NUMBER