1225631062 NPI number — TANYA MICHELLE PEARSON RPH

Table of content: THOMAS KLUMB (NPI 1427181056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225631062 NPI number — TANYA MICHELLE PEARSON RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEARSON
Provider First Name:
TANYA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1225631062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 HEDGEMOOR CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMORY
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38821-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-256-8165
Provider Business Mailing Address Fax Number:
662-256-8186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60379 COTTON GIN PORT RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMORY
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38821-7204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-256-8165
Provider Business Practice Location Address Fax Number:
662-256-8186
Provider Enumeration Date:
11/16/2020

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: 183500000X , with the licence number:  E-08226 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: E-08226 . This is a "STATE LICENSE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".