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NPI Code Detail

MEDICARE: MARK HENDERSON

MEDICARE: MARK HENDERSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacistT09016MS

General Provider Information

NPI Number : 1407138167
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARK HENDERSON
Provider Business Mailing Address
First Line : 6958 GOODMAN RD
Second Line :
City : OLIVE BRANCH
State : MS
Zip : 38654-7034
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 6958 GOODMAN RD
Second Line :
City : OLIVE BRANCH
State : MS
Zip : 38654-7034
Country : US
Telephone Number : 662-890-5047
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/19/2011
Last Update Date : 09/19/2011

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