Provider Demographics
NPI:1740389824
Name:OVERSTREET, ANDREA EWING (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:EWING
Last Name:OVERSTREET
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 1:2015 BENT OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2414
Mailing Address - Country:US
Mailing Address - Phone:228-392-3905
Mailing Address - Fax:228-392-3905
Practice Address - Street 1:10511 DIBERVILLE BLVD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2403
Practice Address - Country:US
Practice Address - Phone:228-392-3905
Practice Address - Fax:228-392-3905
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST09130183500000X
AL12687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0330474Medicaid
MS0330474Medicaid