Provider Demographics
NPI:1740756535
Name:HENRY, JIMMIE ANN
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:ANN
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 NORTHWEST BYP
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-4124
Mailing Address - Country:US
Mailing Address - Phone:406-453-3466
Mailing Address - Fax:
Practice Address - Street 1:401 NORTHWEST BYP
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-4124
Practice Address - Country:US
Practice Address - Phone:406-453-3466
Practice Address - Fax:406-453-3468
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3979OtherPHARMACIST LICENCE
MT0310903856OtherHPSO