Provider Demographics
NPI:1093353807
Name:PITTMAN, SARAH GRACE (PHARMD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:GRACE
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 GLENWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3941
Mailing Address - Country:US
Mailing Address - Phone:601-218-8432
Mailing Address - Fax:
Practice Address - Street 1:3408 PEMBERTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5573
Practice Address - Country:US
Practice Address - Phone:601-630-4003
Practice Address - Fax:601-630-4004
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-13950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist