Provider Demographics
NPI:1669636023
Name:WALTERS, NIKKI RED
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:RED
Last Name:WALTERS
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 1:122 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437-3118
Mailing Address - Country:US
Mailing Address - Phone:601-477-8587
Mailing Address - Fax:601-477-3222
Practice Address - Street 1:122 S FRONT ST
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437-3118
Practice Address - Country:US
Practice Address - Phone:601-477-8587
Practice Address - Fax:601-477-3222
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0013/01.1183500000X
MSE-03592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330679Medicaid