Provider Demographics
NPI:1346842523
Name:MIX, TERRY L (DPH)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:L
Last Name:MIX
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2996 CHURCH RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9825
Mailing Address - Country:US
Mailing Address - Phone:662-349-4418
Mailing Address - Fax:
Practice Address - Street 1:2996 CHURCH RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9825
Practice Address - Country:US
Practice Address - Phone:662-949-4418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS6753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist