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General NPI Number Information
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NPI Number | 1487244802
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Entity Type | Individual
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Provider Name | GEORGE ROBERT REA RPH
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Gender | Male
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Dates
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Enumeration Date | 01/20/2021
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Last Update Date | 01/20/2021
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Provider Practice Location Address
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Address Line | 108 HIGHWAY 12 E
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City | KOSCIUSKO
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State | MS
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Zip | 39090-3304
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Country | US
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Telephone | 662-289-1963
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Fax |
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Provider Business Mailing Address
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Address Line | 11765 HIGHWAY 35 N
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City | KOSCIUSKO
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State | MS
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Zip | 39090-4870
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Country | US
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Telephone | 601-650-8838
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | E-06345
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License Number State | MS
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