Provider Demographics
NPI:1295327971
Name:NORMAN, SALLY R
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:R
Last Name:NORMAN
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 1:276 NISSAN PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-7006
Mailing Address - Country:US
Mailing Address - Phone:601-855-7330
Mailing Address - Fax:601-855-7332
Practice Address - Street 1:276 NISSAN PKWY STE 300
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-7006
Practice Address - Country:US
Practice Address - Phone:601-855-7330
Practice Address - Fax:601-855-7332
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE09754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist