Provider Demographics
NPI:1710656632
Name:PHILIP, MARIAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:PHILIP
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4607
Mailing Address - Country:US
Mailing Address - Phone:601-718-1898
Mailing Address - Fax:
Practice Address - Street 1:971 LAKELAND DR STE 101
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4607
Practice Address - Country:US
Practice Address - Phone:601-718-1898
Practice Address - Fax:601-718-1899
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist