Healthcare Provider Details

I. General information

NPI: 1356387443
Provider Name (Legal Business Name): JERRY MAYBERRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W MAIN ST
CARMI IL
62821-1387
US

IV. Provider business mailing address

202 APRIL AVE
CARMI IL
62821-1545
US

V. Phone/Fax

Practice location:
  • Phone: 618-382-4636
  • Fax: 618-382-7970
Mailing address:
  • Phone: 618-382-8150
  • Fax: 618-382-7970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: