Provider Demographics
NPI:1720626161
Name:EDDLEMON, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:EDDLEMON
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 1:8814 BEATLINE RD
Mailing Address - Street 2:
Mailing Address - City:TUNICA
Mailing Address - State:MS
Mailing Address - Zip Code:38676-9603
Mailing Address - Country:US
Mailing Address - Phone:901-568-1102
Mailing Address - Fax:
Practice Address - Street 1:465 STATELINE RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1611
Practice Address - Country:US
Practice Address - Phone:662-393-3426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07251183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1720626161Medicaid