Provider Demographics
NPI:1740882893
Name:ARMISTEAD, AUDRA
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:ARMISTEAD
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 1:122 W COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-3410
Mailing Address - Country:US
Mailing Address - Phone:662-728-5732
Mailing Address - Fax:662-728-5756
Practice Address - Street 1:122 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3410
Practice Address - Country:US
Practice Address - Phone:662-728-5732
Practice Address - Fax:662-728-5756
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE08527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist