Provider Demographics
NPI:1053528984
Name:TAYLOR, JIMMY MIKE
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:MIKE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 ISLAND VIEW CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-6015
Mailing Address - Country:US
Mailing Address - Phone:912-727-3010
Mailing Address - Fax:
Practice Address - Street 1:110 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-1956
Practice Address - Country:US
Practice Address - Phone:912-748-3194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14254183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist