Provider Demographics
NPI:1225639248
Name:PATTON, JOHNNIE L
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:L
Last Name:PATTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 S WHEATLEY ST
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5002
Mailing Address - Country:US
Mailing Address - Phone:601-209-6513
Mailing Address - Fax:
Practice Address - Street 1:815 S WHEATLEY ST
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5002
Practice Address - Country:US
Practice Address - Phone:601-957-1603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR-40343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy