Provider Demographics
NPI:1952828147
Name:BIRMINGHAM, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BIRMINGHAM
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 1:2945 LAYFAIR DR APT 1217
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9769
Mailing Address - Country:US
Mailing Address - Phone:662-542-1311
Mailing Address - Fax:
Practice Address - Street 1:1220 JERRY CLOWER BLVD
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-3077
Practice Address - Country:US
Practice Address - Phone:662-746-9926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-15043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist