Healthcare Provider Details

I. General information

NPI: 1386720431
Provider Name (Legal Business Name): LARRY H MELTON RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15917 BOUNDARY DR
ASHLAND MS
38603-0126
US

IV. Provider business mailing address

PO BOX 126
ASHLAND MS
38603-0126
US

V. Phone/Fax

Practice location:
  • Phone: 662-224-8922
  • Fax: 662-224-9111
Mailing address:
  • Phone: 662-224-8922
  • Fax: 662-224-9111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE6060
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: