Healthcare Provider Details

I. General information

NPI: 1295944072
Provider Name (Legal Business Name): MR. JACKIE ROSS SIMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 PASEO DEL PUEBLO SUR STE A 5401 NDCBU
TAOS NM
87571-5101
US

IV. Provider business mailing address

26058 TAOS CANYON, HWY 64 HC 71 BOX 77
TAOS NM
87571-9501
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-3342
  • Fax:
Mailing address:
  • Phone: 505-758-8309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6447
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: