Provider Demographics
NPI:1407560212
Name:MENNEFIELD, DWAYNE PATRICK (RPH)
Entity Type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:PATRICK
Last Name:MENNEFIELD
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 1:160 HARTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6544
Mailing Address - Country:US
Mailing Address - Phone:601-201-1320
Mailing Address - Fax:
Practice Address - Street 1:977 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-6256
Practice Address - Country:US
Practice Address - Phone:601-944-9965
Practice Address - Fax:601-969-6419
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-083061835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care