=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669344552
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABDEREZAK SHIFA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2025
-----------------------------------------------------
Last Update Date | 09/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 830 S GLOSTER ST
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38801-4996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-377-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4100 N GLOSTER ST APT I204
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38804-7220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-602-7799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | E-101261
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------