Provider Demographics
NPI:1295213056
Name:PAGE, STANLEY
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:PAGE
Suffix:
Gender:M
Credentials:
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 369
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:MS
Mailing Address - Zip Code:38873-0369
Mailing Address - Country:US
Mailing Address - Phone:662-438-6605
Mailing Address - Fax:662-438-6680
Practice Address - Street 1:18 FIRST AVE
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:MS
Practice Address - Zip Code:38873-8441
Practice Address - Country:US
Practice Address - Phone:662-438-6605
Practice Address - Fax:662-438-6680
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD-06648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD-06648OtherMS STATE LICENSE