Provider Demographics
NPI:1821366279
Name:MORRIS, JONETHAN MICHAEL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JONETHAN
Middle Name:MICHAEL
Last Name:MORRIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 PARK LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4125
Mailing Address - Country:US
Mailing Address - Phone:662-416-2295
Mailing Address - Fax:
Practice Address - Street 1:977 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-6256
Practice Address - Country:US
Practice Address - Phone:601-944-9965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP11723183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP11723OtherPHARMACIST LICENSE