Provider Demographics
NPI:1073113551
Name:SEWELL, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SEWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3929 N GLOSTER ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-0915
Mailing Address - Country:US
Mailing Address - Phone:662-840-5546
Mailing Address - Fax:
Practice Address - Street 1:3929 N GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-0915
Practice Address - Country:US
Practice Address - Phone:662-840-5546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-010201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist