Provider Demographics
NPI:1023398120
Name:FORD, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 IRIS LN
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4400
Mailing Address - Country:US
Mailing Address - Phone:318-641-1746
Mailing Address - Fax:
Practice Address - Street 1:604 MACARTHUR DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3111
Practice Address - Country:US
Practice Address - Phone:318-442-5710
Practice Address - Fax:318-442-4487
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16775183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist