Provider Demographics
NPI:1265037774
Name:BRANCH, ROBERT1 K (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT1
Middle Name:K
Last Name:BRANCH
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 1:1420 CANTON MART RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5434
Mailing Address - Country:US
Mailing Address - Phone:601-956-5143
Mailing Address - Fax:601-956-7538
Practice Address - Street 1:1420 CANTON MART RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5434
Practice Address - Country:US
Practice Address - Phone:601-956-5143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST12046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist