Healthcare Provider Details

I. General information

NPI: 1265022115
Provider Name (Legal Business Name): RANDALL MOY PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 HIGHWAY 19 N
MERIDIAN MS
39307-9377
US

IV. Provider business mailing address

2400 HIGHWAY 19 N
MERIDIAN MS
39307-9377
US

V. Phone/Fax

Practice location:
  • Phone: 601-482-3170
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-15496
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: