Provider Demographics
NPI:1356637524
Name:GARDNER, DOUGLAS EDWARD (RPH)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:GARDNER
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 1:465 STATELINE RD W
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1611
Mailing Address - Country:US
Mailing Address - Phone:662-393-3426
Mailing Address - Fax:662-393-1605
Practice Address - Street 1:465 STATELINE RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1611
Practice Address - Country:US
Practice Address - Phone:662-393-3426
Practice Address - Fax:662-393-1605
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-25
Last Update Date:2011-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-6112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist