Healthcare Provider Details

I. General information

NPI: 1649865635
Provider Name (Legal Business Name): PAM ANNE LEWIS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 SUNSET DR
GRENADA MS
38901-4613
US

IV. Provider business mailing address

131 COUNTY ROAD 327
BIG CREEK MS
38914-2622
US

V. Phone/Fax

Practice location:
  • Phone: 662-417-8660
  • Fax: 662-307-2750
Mailing address:
  • Phone: 662-645-2331
  • Fax: 662-628-4590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberE06013
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: