Healthcare Provider Details

I. General information

NPI: 1962700435
Provider Name (Legal Business Name): JIM EVERETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 HIGHWAY 277 N
SONORA TX
76950-2204
US

IV. Provider business mailing address

P.O. BOX 527
SONORA TX
76950-0527
US

V. Phone/Fax

Practice location:
  • Phone: 325-387-2541
  • Fax: 325-387-5423
Mailing address:
  • Phone: 325-387-2541
  • Fax: 325-387-5423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18546
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number23182
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: