Provider Demographics
NPI:1417380973
Name:GRAHAM, MARK ALAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:GRAHAM
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 1:4329 N STATE ST
Mailing Address - Street 2:STE #10
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5261
Mailing Address - Country:US
Mailing Address - Phone:601-366-1449
Mailing Address - Fax:601-366-3553
Practice Address - Street 1:4329 N STATE ST
Practice Address - Street 2:STE #10
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5261
Practice Address - Country:US
Practice Address - Phone:601-366-1449
Practice Address - Fax:601-366-3553
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
MSE6023183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist