Provider Demographics
NPI:1760664619
Name:PAMELA B LEDBETTER
Entity Type:Organization
Organization Name:PAMELA B LEDBETTER
Other - Org Name:VANJON'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMIST
Authorized Official - Phone:662-746-3565
Mailing Address - Street 1:320 E FIFTEENTH ST
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-2632
Mailing Address - Country:US
Mailing Address - Phone:662-746-3562
Mailing Address - Fax:662-746-3568
Practice Address - Street 1:320 E FIFTEENTH ST
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-2632
Practice Address - Country:US
Practice Address - Phone:662-746-3562
Practice Address - Fax:662-746-3568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05253364Medicaid
MS05253364Medicaid
MS0566440001Medicare UPIN