{
"Npi": {
"NPI": "1487244802",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "REA",
"FirstName": "GEORGE",
"MiddleName": "ROBERT",
"NamePrefix": "MR.",
"NameSuffix": null,
"Credential": "RPH",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "11765 HIGHWAY 35 N",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "KOSCIUSKO",
"MailingAddressStateName": "MS",
"MailingAddressPostalCode": "39090-4870",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "601-650-8838",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "108 HIGHWAY 12 E",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "KOSCIUSKO",
"PracticeLocationAddressStateName": "MS",
"PracticeLocationAddressPostalCode": "39090-3304",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "662-289-1963",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "01/20/2021",
"LastUpdateDate": "01/20/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "183500000X",
"TaxonomyName": "Pharmacist",
"LicenseNumber": "E-06345",
"LicenseNumberStateCode": "MS",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}