Healthcare Provider Details

I. General information

NPI: 1720690498
Provider Name (Legal Business Name): KELSEY BARNETT MIZE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2020
Last Update Date: 08/23/2020
Certification Date: 08/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4028 GOODMAN RD W
HORN LAKE MS
38637-1325
US

IV. Provider business mailing address

4028 GOODMAN RD W
HORN LAKE MS
38637-1325
US

V. Phone/Fax

Practice location:
  • Phone: 662-393-3477
  • Fax: 662-393-3214
Mailing address:
  • Phone: 662-393-3477
  • Fax: 662-393-3214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-16140
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: