Provider Demographics
NPI:1437467800
Name:PRESTAGE, WILLIAM BRYCE (RPH)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRYCE
Last Name:PRESTAGE
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 1:441 N FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:BALDWYN
Mailing Address - State:MS
Mailing Address - Zip Code:38824-1525
Mailing Address - Country:US
Mailing Address - Phone:662-365-8877
Mailing Address - Fax:662-365-8777
Practice Address - Street 1:441 N FOURTH ST
Practice Address - Street 2:
Practice Address - City:BALDWYN
Practice Address - State:MS
Practice Address - Zip Code:38824-1525
Practice Address - Country:US
Practice Address - Phone:662-365-8877
Practice Address - Fax:662-365-8777
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-05788183500000X
FLPS 35588183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist