Provider Demographics
NPI:1851994610
Name:RICHARD, DEJUANA (PHARMD)
Entity Type:Individual
Prefix:
First Name:DEJUANA
Middle Name:
Last Name:RICHARD
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 1:2076 ALBERTA DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:MS
Mailing Address - Zip Code:39652-4099
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1619 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3609
Practice Address - Country:US
Practice Address - Phone:601-684-8670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-15001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist