1083176283 NPI number — MRS. MARY CLAIRE JOLLY FITTER/DISPENSER

Table of content: MRS. MARY CLAIRE JOLLY FITTER/DISPENSER (NPI 1083176283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083176283 NPI number — MRS. MARY CLAIRE JOLLY FITTER/DISPENSER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOLLY
Provider First Name:
MARY
Provider Middle Name:
CLAIRE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FITTER/DISPENSER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083176283
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
346 BAGANIE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BULLARD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75757-3010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-330-6798
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4746 S BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-561-8774
Provider Business Practice Location Address Fax Number:
903-561-8787
Provider Enumeration Date:
04/05/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  80480 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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