Provider Demographics
NPI:1720357809
Name:HUMPHRIES, CLAIRE
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:
Last Name:HUMPHRIES
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 1:3255 SHADY LAKE DR.
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632
Mailing Address - Country:US
Mailing Address - Phone:901-921-9755
Mailing Address - Fax:
Practice Address - Street 1:950 COMMERCE ST.
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632
Practice Address - Country:US
Practice Address - Phone:662-429-3349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-09705183500000X
TN0000013044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist