Healthcare Provider Details

I. General information

NPI: 1508467341
Provider Name (Legal Business Name): MAKENA BOEHM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 HIGHWAY 51 N
SENATOBIA MS
38668-1719
US

IV. Provider business mailing address

190 LOVE RD
HERNANDO MS
38632-0400
US

V. Phone/Fax

Practice location:
  • Phone: 662-562-8266
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE010547
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: