Healthcare Provider Details

I. General information

NPI: 1760896153
Provider Name (Legal Business Name): ROBERT TERRY DALTON JR. R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S HIGHWAY 365
BURNSVILLE MS
38833-9706
US

IV. Provider business mailing address

603 S HIGHWAY 365
BURNSVILLE MS
38833-9706
US

V. Phone/Fax

Practice location:
  • Phone: 662-427-0200
  • Fax: 662-427-0101
Mailing address:
  • Phone: 662-427-0200
  • Fax: 662-427-0101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-07806
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: