Healthcare Provider Details

I. General information

NPI: 1164326047
Provider Name (Legal Business Name): KRISHTAN SAMUEL FARRAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1893 CLIFF GOOKIN BLVD
TUPELO MS
38801-6558
US

IV. Provider business mailing address

PO BOX 68
TUPELO MS
38802-0068
US

V. Phone/Fax

Practice location:
  • Phone: 662-584-5097
  • Fax:
Mailing address:
  • Phone: 662-205-0098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: