1003185471 NPI number — MISS MOLLIE MCGINNIS KIDDER PHARM D

Table of content: GERALDINE S. KOPPENAAL RNCS (NPI 1629023940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003185471 NPI number — MISS MOLLIE MCGINNIS KIDDER PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIDDER
Provider First Name:
MOLLIE
Provider Middle Name:
MCGINNIS
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PHARM D
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:
1003185471
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
302 COLONY RIDGE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39157-2019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-926-1179
Provider Business Mailing Address Fax Number:
601-926-1234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 HIGHWAY 80 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39056-4716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-926-1179
Provider Business Practice Location Address Fax Number:
601-926-1234
Provider Enumeration Date:
12/14/2011

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-11936 , 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)





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