Provider Demographics
NPI:1780689240
Name:LOMENICK, ROBERT H (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:H
Last Name:LOMENICK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 E VAN DORN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-3025
Mailing Address - Country:US
Mailing Address - Phone:662-252-2446
Mailing Address - Fax:662-252-4379
Practice Address - Street 1:145 E VAN DORN AVE
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-3025
Practice Address - Country:US
Practice Address - Phone:662-252-2446
Practice Address - Fax:662-252-4379
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE06294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06202021Medicaid