Provider Demographics
NPI:1518569045
Name:LAVENDER, PATRICIA DENISE
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DENISE
Last Name:LAVENDER
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 1:493 RENON LN
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MS
Mailing Address - Zip Code:39740-8689
Mailing Address - Country:US
Mailing Address - Phone:662-547-9432
Mailing Address - Fax:662-327-0236
Practice Address - Street 1:1913 HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1950
Practice Address - Country:US
Practice Address - Phone:662-329-1766
Practice Address - Fax:662-327-0236
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE7523183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist