Healthcare Provider Details

I. General information

NPI: 1750472569
Provider Name (Legal Business Name): TIFFANY N. MOREIRA RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA MEDICAL CENTER -OUTPATIENT PHARMACY 1500 E. WOODROW WILSON DR
JACKSON MS
39216-5199
US

IV. Provider business mailing address

171 N. MAPLE ST
RIDGELAND MS
39157-2308
US

V. Phone/Fax

Practice location:
  • Phone: 601-364-1557
  • Fax: 601-364-1548
Mailing address:
  • Phone: 601-364-1555
  • Fax: 601-364-1548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberT-08168
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: