Healthcare Provider Details

I. General information

NPI: 1801488846
Provider Name (Legal Business Name): ALLEN ELLIOTT LANE RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4931 MAIN ST
MOSS POINT MS
39563-2746
US

IV. Provider business mailing address

PO BOX 8647
MOSS POINT MS
39562-0010
US

V. Phone/Fax

Practice location:
  • Phone: 228-474-4663
  • Fax: 228-474-5545
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberE-07228
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: