Provider Demographics
NPI:1699392902
Name:HART, DERRELL DEWAYNE JR (PHARMD)
Entity Type:Individual
Prefix:
First Name:DERRELL
Middle Name:DEWAYNE
Last Name:HART
Suffix:JR
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 1:1167 HIGHWAY 49 S
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-4409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1167 HIGHWAY 49 S
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-4409
Practice Address - Country:US
Practice Address - Phone:601-664-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-165491835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist