Provider Demographics
NPI:1508467341
Name:BOEHM, MAKENA
Entity Type:Individual
Prefix:
First Name:MAKENA
Middle Name:
Last Name:BOEHM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 LOVE RD
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-0400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5219 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-1719
Practice Address - Country:US
Practice Address - Phone:662-562-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE010547183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist