Healthcare Provider Details

I. General information

NPI: 1669344552
Provider Name (Legal Business Name): ABDEREZAK SHIFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2025
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4996
US

IV. Provider business mailing address

4100 N GLOSTER ST APT I204
TUPELO MS
38804-7220
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3000
  • Fax:
Mailing address:
  • Phone: 615-602-7799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-101261
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: