Provider Demographics
NPI:1578163929
Name:HORN, LORI BOLEN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:BOLEN
Last Name:HORN
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 1:300 WALMART CIR
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-1018
Mailing Address - Country:US
Mailing Address - Phone:662-728-6863
Mailing Address - Fax:662-728-7014
Practice Address - Street 1:300 WALMART CIR
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-1018
Practice Address - Country:US
Practice Address - Phone:662-728-6863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE8206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist