Provider Demographics
NPI:1710016233
Name:JELKS, JAMES L JR (R PH)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:L
Last Name:JELKS
Suffix:JR
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 159
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631-0159
Mailing Address - Country:US
Mailing Address - Phone:601-645-5411
Mailing Address - Fax:601-645-6454
Practice Address - Street 1:149 MAIN ST.
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MS
Practice Address - Zip Code:39631-0159
Practice Address - Country:US
Practice Address - Phone:601-645-5411
Practice Address - Fax:601-645-6454
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-06942183500000X
332B00000X
MS016493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440293Medicaid
MS00030372Medicaid
MS00440293Medicaid