MEDICARE: MRS. PAMILA SUE FERGUSON

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
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	E-010394	MS

General Provider Information

NPI Number	:	1679829626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAMILA SUE FERGUSON

Provider Business Mailing Address
First Line	:	5001 MAIN ST
Second Line	:
City	:	MOSS POINT
State	:	MS
Zip	:	39563-2738
Country	:	US
Telephone Number	:	228-471-1397
Fax Number	:	228-471-1400

Provider Business Practice Location Address
First Line	:	5001 MAIN ST
Second Line	:
City	:	MOSS POINT
State	:	MS
Zip	:	39563-2738
Country	:	US
Telephone Number	:	228-471-1397
Fax Number	:	228-471-1400

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2012
Last Update Date	:	07/27/2012

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