Provider Demographics
NPI:1376976845
Name:THERRELL, WALTON FRANK (RPH)
Entity Type:Individual
Prefix:
First Name:WALTON
Middle Name:FRANK
Last Name:THERRELL
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 1:915 HILL ST
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-2419
Mailing Address - Country:US
Mailing Address - Phone:601-477-3573
Mailing Address - Fax:
Practice Address - Street 1:915 HILL ST
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-2419
Practice Address - Country:US
Practice Address - Phone:601-477-3573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE6418183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist