Provider Demographics
NPI:1316373483
Name:REVES, SANDRA MITCHELL (RPH)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MITCHELL
Last Name:REVES
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 1:218 SUNSET CIR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7003
Mailing Address - Country:US
Mailing Address - Phone:601-856-4504
Mailing Address - Fax:
Practice Address - Street 1:218 SUNSET CIR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7003
Practice Address - Country:US
Practice Address - Phone:601-856-4504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist