Provider Demographics
NPI:1033248372
Name:LEWIS, PAUL ROBERSON (RPH)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ROBERSON
Last Name:LEWIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 GLEN TRL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6355
Mailing Address - Country:US
Mailing Address - Phone:601-421-4597
Mailing Address - Fax:601-919-0017
Practice Address - Street 1:202 GLEN TRL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6355
Practice Address - Country:US
Practice Address - Phone:601-421-4597
Practice Address - Fax:601-919-0017
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist