Provider Demographics
NPI:1063014728
Name:CASEY, ETHAN CONRAD (PHARMD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:CONRAD
Last Name:CASEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-0300
Mailing Address - Country:US
Mailing Address - Phone:662-253-6181
Mailing Address - Fax:
Practice Address - Street 1:4150 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-0300
Practice Address - Country:US
Practice Address - Phone:662-253-6181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE14919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist