Healthcare Provider Details

I. General information

NPI: 1487664637
Provider Name (Legal Business Name): JIMMY L GARRISON BSRPH/PD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 HIGH RIDGE BLVD
HIGH RIDGE MO
63049-2202
US

IV. Provider business mailing address

1620 CHALMERS DR
CHESTERFIELD MO
63017-5615
US

V. Phone/Fax

Practice location:
  • Phone: 636-677-3900
  • Fax: 636-677-7795
Mailing address:
  • Phone: 636-532-1145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number027630
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: