Provider Demographics
NPI:1164572848
Name:GRAHAM, PHILIP RANDLE (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:RANDLE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087908Medicaid
MS0695680001Medicare NSC
MS560948822Medicare PIN