Provider Demographics
NPI:1942960489
Name:WARREN, JONTAE DEION (PHARMD)
Entity Type:Individual
Prefix:
First Name:JONTAE
Middle Name:DEION
Last Name:WARREN
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:PO BOX 534
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-0534
Mailing Address - Country:US
Mailing Address - Phone:662-416-4350
Mailing Address - Fax:
Practice Address - Street 1:2700 NAPOLEON AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-6914
Practice Address - Country:US
Practice Address - Phone:504-897-5813
Practice Address - Fax:425-620-3727
Is Sole Proprietor?:No
Enumeration Date:2021-12-25
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE100311183500000X
IN26029254A183500000X
LAPST.024890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist