Healthcare Provider Details

I. General information

NPI: 1528339983
Provider Name (Legal Business Name): VICKIE C EDDLEMON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 MOUNT PLEASANT RD
HERNANDO MS
38632-1909
US

IV. Provider business mailing address

2775 ANTHONY CV
NESBIT MS
38651-9200
US

V. Phone/Fax

Practice location:
  • Phone: 901-496-9347
  • Fax:
Mailing address:
  • Phone: 901-496-9347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberE-09316
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: