Provider Demographics
NPI:1508371675
Name:FAIR, CAROLINE BOYDSTUN (PHARMD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:BOYDSTUN
Last Name:FAIR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 NORTHSIDE SHOPPING CENTER
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090
Mailing Address - Country:US
Mailing Address - Phone:662-803-2641
Mailing Address - Fax:
Practice Address - Street 1:109 NORTHSIDE CENTER
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090
Practice Address - Country:US
Practice Address - Phone:662-289-3234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-14947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist