Provider Demographics
NPI:1164528477
Name:DIVINITY, DEWITT (RPH)
Entity Type:Individual
Prefix:
First Name:DEWITT
Middle Name:
Last Name:DIVINITY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E WOODROW WILSON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5199
Mailing Address - Country:US
Mailing Address - Phone:601-364-1555
Mailing Address - Fax:601-364-1578
Practice Address - Street 1:1500 E WOODROW WILSON DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5199
Practice Address - Country:US
Practice Address - Phone:601-364-1555
Practice Address - Fax:601-364-1578
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-09554183500000X
TX39763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist