Provider Demographics
NPI:1790389047
Name:JEFFRIES, EDWARD GARRETT
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:GARRETT
Last Name:JEFFRIES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 E FORT ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61531-9572
Mailing Address - Country:US
Mailing Address - Phone:309-245-2335
Mailing Address - Fax:309-245-2632
Practice Address - Street 1:1050 E FORT ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61531-9572
Practice Address - Country:US
Practice Address - Phone:309-245-2335
Practice Address - Fax:309-245-2632
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist