Provider Demographics
NPI:1942396569
Name:HARRIS, WILLIE CLEO JR
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:CLEO
Last Name:HARRIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WILLIE
Other - Middle Name:CLEO
Other - Last Name:HARRIS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:P.O. BOX 6012
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MI
Mailing Address - Zip Code:39288-6012
Mailing Address - Country:US
Mailing Address - Phone:601-364-1556
Mailing Address - Fax:601-364-1548
Practice Address - Street 1:VA MEDICAL CENTER PHARMACY
Practice Address - Street 2:1500 E WOODROW WILSON AVE
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:39216-5199
Practice Address - Country:US
Practice Address - Phone:601-364-1556
Practice Address - Fax:601-364-1548
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-4082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist