Healthcare Provider Details

I. General information

NPI: 1407560212
Provider Name (Legal Business Name): DWAYNE PATRICK MENNEFIELD RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 ELLIS AVE
JACKSON MS
39209-6256
US

IV. Provider business mailing address

160 HARTFIELD DR
MADISON MS
39110-6544
US

V. Phone/Fax

Practice location:
  • Phone: 601-944-9965
  • Fax: 601-969-6419
Mailing address:
  • Phone: 601-201-1320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberE-08306
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: