Provider Demographics
NPI:1467056044
Name:BOYD, MITZI (RPH)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:
Last Name:BOYD
Suffix:
Gender:F
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:PO BOX 983
Mailing Address - Street 2:
Mailing Address - City:TUNICA
Mailing Address - State:MS
Mailing Address - Zip Code:38676-0983
Mailing Address - Country:US
Mailing Address - Phone:662-910-0096
Mailing Address - Fax:
Practice Address - Street 1:425 DESOTO AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-5214
Practice Address - Country:US
Practice Address - Phone:662-627-0100
Practice Address - Fax:662-627-0102
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-06447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist