Healthcare Provider Details

I. General information

NPI: 1144622895
Provider Name (Legal Business Name): NICOLE COUSIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 09/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 FRONTAGE RD
PICAYUNE MS
39466-7587
US

IV. Provider business mailing address

235 FRONTAGE RD
PICAYUNE MS
39466-7587
US

V. Phone/Fax

Practice location:
  • Phone: 601-799-1063
  • Fax:
Mailing address:
  • Phone: 601-799-1063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE08848
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: