Provider Demographics
NPI:1114166931
Name:PHILIP R GRAHAM & WILLIAM J
Entity Type:Organization
Organization Name:PHILIP R GRAHAM & WILLIAM J
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:662-489-4741
Mailing Address - Street 1:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-0120
Mailing Address - Country:US
Mailing Address - Phone:662-489-4741
Mailing Address - Fax:662-489-2940
Practice Address - Street 1:14 E MARION ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-2813
Practice Address - Country:US
Practice Address - Phone:662-489-4741
Practice Address - Fax:662-489-2940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0695680001Medicare NSC