Provider Demographics
NPI:1841597358
Name:PROKUP, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PROKUP
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 1:29936 JULY RD
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MO
Mailing Address - Zip Code:63549-3129
Mailing Address - Country:US
Mailing Address - Phone:660-332-4456
Mailing Address - Fax:
Practice Address - Street 1:29936 JULY RD
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MO
Practice Address - Zip Code:63549-3129
Practice Address - Country:US
Practice Address - Phone:660-332-4456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600133003Medicaid