Provider Demographics
NPI:1326605106
Name:BROWN, EUGENE FRANKLIN JR
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:FRANKLIN
Last Name:BROWN
Suffix:JR
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 1:10050 ROAD 547
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-7900
Mailing Address - Country:US
Mailing Address - Phone:601-504-8369
Mailing Address - Fax:
Practice Address - Street 1:584 E MAIN ST STE B3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2330
Practice Address - Country:US
Practice Address - Phone:601-656-2272
Practice Address - Fax:601-650-9040
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE08931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00091847Medicaid