Provider Demographics
NPI:1750672366
Name:HARRIS, MACK
Entity type:Individual
Prefix:
First Name:MACK
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 24TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-3405
Mailing Address - Country:US
Mailing Address - Phone:228-864-4626
Mailing Address - Fax:
Practice Address - Street 1:4031 POPPS FERRY RD STE A
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2367
Practice Address - Country:US
Practice Address - Phone:228-392-7310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-05559183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist