Provider Demographics
NPI:1235451527
Name:CAMPBELL, MYRA MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:MARIE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 DANEY ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3713
Mailing Address - Country:US
Mailing Address - Phone:228-467-6804
Mailing Address - Fax:228-467-7964
Practice Address - Street 1:344 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:WAVELAND
Practice Address - State:MS
Practice Address - Zip Code:39576-2672
Practice Address - Country:US
Practice Address - Phone:228-467-6804
Practice Address - Fax:228-467-7964
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-27
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-07948183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist