Provider Demographics
NPI:1154630143
Name:BOZONE, DAVID E JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:E
Last Name:BOZONE
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:E
Other - Last Name:BOZONE
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:5760 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-8930
Mailing Address - Country:US
Mailing Address - Phone:601-664-0202
Mailing Address - Fax:601-664-0730
Practice Address - Street 1:5760 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-8930
Practice Address - Country:US
Practice Address - Phone:601-664-0202
Practice Address - Fax:601-664-0730
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE5004183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT00330589Medicaid