Healthcare Provider Details

I. General information

NPI: 1740389824
Provider Name (Legal Business Name): ANDREA EWING OVERSTREET RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10511 DIBERVILLE BLVD
DIBERVILLE MS
39540-2403
US

IV. Provider business mailing address

2015 BENT OAKS BLVD
BILOXI MS
39531-2414
US

V. Phone/Fax

Practice location:
  • Phone: 228-392-3905
  • Fax: 228-392-3905
Mailing address:
  • Phone: 228-392-3905
  • Fax: 228-392-3905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberT09130
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12687
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: