Healthcare Provider Details

I. General information

NPI: 1801192257
Provider Name (Legal Business Name): LAURA JO GARDNER PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 S CENTER ST
POTTS CAMP MS
38659-9531
US

IV. Provider business mailing address

525 HIGHWAY 30 W
BALDWYN MS
38824-9051
US

V. Phone/Fax

Practice location:
  • Phone: 662-333-7782
  • Fax:
Mailing address:
  • Phone: 662-365-5534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE09336
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: