=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437726700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY WAYNE MORTON RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2021
-----------------------------------------------------
Last Update Date | 06/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4206 RIDGE ROAD
-----------------------------------------------------
City | ROCKWALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-722-2040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4206 RIDGE ROAD
-----------------------------------------------------
City | ROCKWALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-722-2040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 20796
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------