Provider Demographics
NPI:1821593963
Name:THOMPSON, GENA GEORGANNE
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:GEORGANNE
Last Name:THOMPSON
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 1:130 HIGHLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-5574
Mailing Address - Country:US
Mailing Address - Phone:601-358-9695
Mailing Address - Fax:
Practice Address - Street 1:130 HIGHLAND PKWY
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5574
Practice Address - Country:US
Practice Address - Phone:601-358-9695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-075511835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist