Healthcare Provider Details

I. General information

NPI: 1902443963
Provider Name (Legal Business Name): JASON SESTI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 GOODMAN RD E
SOUTHAVEN MS
38672-8707
US

IV. Provider business mailing address

3095 GOODMAN RD E
SOUTHAVEN MS
38672-8707
US

V. Phone/Fax

Practice location:
  • Phone: 662-536-3743
  • Fax: 662-536-3746
Mailing address:
  • Phone: 662-536-3743
  • Fax: 662-536-3746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-09804
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberE-09804
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: