Healthcare Provider Details

I. General information

NPI: 1982122289
Provider Name (Legal Business Name): DR. CARROLL BRUISTER III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 MABUS
ACKERMAN MS
39735
US

IV. Provider business mailing address

11850 MS HWY 15
ACKERMAN MS
39735
US

V. Phone/Fax

Practice location:
  • Phone: 662-285-6039
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE6788
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: