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General NPI Number Information
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NPI Number | 1801488846
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Entity Type | Individual
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Provider Name | ALLEN ELLIOTT LANE RPH.
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Gender | Male
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Dates
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Enumeration Date | 02/10/2021
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Last Update Date | 02/10/2021
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Provider Practice Location Address
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Address Line | 4931 MAIN ST
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City | MOSS POINT
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State | MS
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Zip | 39563-2746
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Country | US
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Telephone | 228-474-4663
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Fax | 228-474-5545
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Provider Business Mailing Address
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Address Line | PO BOX 8647
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City | MOSS POINT
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State | MS
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Zip | 39562-0010
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Country | US
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Telephone |
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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 | 1835P2201X
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Taxonomy Name | Ambulatory Care Pharmacist
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License Number | E-07228
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License Number State | MS
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