Provider Demographics
NPI:1861860660
Name:BOSSE, JEFFERY
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:BOSSE
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 1:1038 US HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-2114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1038 US HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2114
Practice Address - Country:US
Practice Address - Phone:912-748-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028790183500000X
SCPH.36320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist