Provider Demographics
NPI:1518505320
Name:POWELL, DEONTE R SR (PHARMD)
Entity Type:Individual
Prefix:
First Name:DEONTE
Middle Name:R
Last Name:POWELL
Suffix:SR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2320
Mailing Address - Country:US
Mailing Address - Phone:601-218-1544
Mailing Address - Fax:
Practice Address - Street 1:1778 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7801
Practice Address - Country:US
Practice Address - Phone:601-218-1544
Practice Address - Fax:662-332-0232
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-14095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist