Provider Demographics
NPI:1184617458
Name:GRAHAM, THOMAS G JR (MD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:G
Last Name:GRAHAM
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. DRAWER B
Mailing Address - Street 2:111 SOUTH SECOND ST
Mailing Address - City:BALDWYN
Mailing Address - State:MS
Mailing Address - Zip Code:38824
Mailing Address - Country:US
Mailing Address - Phone:662-365-5294
Mailing Address - Fax:662-365-5295
Practice Address - Street 1:P.O. DRAWER B
Practice Address - Street 2:111 SOUTH SECOND ST
Practice Address - City:BALDWYN
Practice Address - State:MS
Practice Address - Zip Code:38824
Practice Address - Country:US
Practice Address - Phone:662-365-5294
Practice Address - Fax:662-365-5295
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE5900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440670Medicaid
MS0525020001Medicare ID - Type Unspecified