Provider Demographics
NPI:1336703362
Name:BOUTWELL, WILLIAM KELLY (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:KELLY
Last Name:BOUTWELL
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 1:428 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2351
Mailing Address - Country:US
Mailing Address - Phone:601-833-7455
Mailing Address - Fax:601-833-3987
Practice Address - Street 1:428 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2351
Practice Address - Country:US
Practice Address - Phone:601-833-7455
Practice Address - Fax:601-833-3987
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE08687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist