Provider Demographics
NPI:1265558209
Name:MCCULLOUGH, JESSE WILLIAM SR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:WILLIAM
Last Name:MCCULLOUGH
Suffix:SR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4029 FRANKLIN PIKE
Mailing Address - Street 2:
Mailing Address - City:COCHRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:16314-7005
Mailing Address - Country:US
Mailing Address - Phone:814-425-1078
Mailing Address - Fax:
Practice Address - Street 1:1020 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:PA
Practice Address - Zip Code:16323-1215
Practice Address - Country:US
Practice Address - Phone:814-432-4824
Practice Address - Fax:814-437-2312
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP045508L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist