Provider Demographics
NPI:1952691487
Name:FORTENBERRY, JERRY MATTHEW
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:MATTHEW
Last Name:FORTENBERRY
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 1:1800 HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2110
Mailing Address - Country:US
Mailing Address - Phone:662-327-6138
Mailing Address - Fax:
Practice Address - Street 1:1800 HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2110
Practice Address - Country:US
Practice Address - Phone:662-327-6138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE6839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist