Healthcare Provider Details

I. General information

NPI: 1457086712
Provider Name (Legal Business Name): COLEMAN SISSON PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W CENTRAL AVE
PETAL MS
39465-2313
US

IV. Provider business mailing address

3 RIVIERA CIR
HATTIESBURG MS
39402-8681
US

V. Phone/Fax

Practice location:
  • Phone: 601-554-3236
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-100783
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: