Healthcare Provider Details

I. General information

NPI: 1942490099
Provider Name (Legal Business Name): IRISH E LYTLE R PHE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 JOHN R JUNKIN DR
NATCHEZ MS
39120-3822
US

IV. Provider business mailing address

6 ALTA RD
NATCHEZ MS
39120-4902
US

V. Phone/Fax

Practice location:
  • Phone: 601-442-0086
  • Fax: 601-442-4806
Mailing address:
  • Phone: 601-442-1684
  • Fax: 601-442-4806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE8010
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE 8010
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: