MEDICARE: GENA GEORGANNE THOMPSON

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-07551	MS

General Provider Information

NPI Number	:	1821593963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENA GEORGANNE THOMPSON

Provider Business Mailing Address
First Line	:	130 HIGHLAND PKWY
Second Line	:
City	:	PICAYUNE
State	:	MS
Zip	:	39466-5574
Country	:	US
Telephone Number	:	601-358-9695
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 HIGHLAND PKWY
Second Line	:
City	:	PICAYUNE
State	:	MS
Zip	:	39466-5574
Country	:	US
Telephone Number	:	601-358-9695
Fax Number	:

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

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	03/29/2018

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Directions to “ GENA GEORGANNE THOMPSON ” Practice Location

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