Healthcare Provider Details

I. General information

NPI: 1659094613
Provider Name (Legal Business Name): OLIVIA WATERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 HIGHWAY 72 W
CORINTH MS
38834-5511
US

IV. Provider business mailing address

104 HIGHWAY 72 W
CORINTH MS
38834-5511
US

V. Phone/Fax

Practice location:
  • Phone: 662-287-8304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number023113
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number46582
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number100895
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: