Provider Demographics
NPI:1750982104
Name:MCELROY-LIDDELL, STEPHANIE (PHARM D)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MCELROY-LIDDELL
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 CRESTON DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-3003
Mailing Address - Country:US
Mailing Address - Phone:601-454-4697
Mailing Address - Fax:
Practice Address - Street 1:90 BASS PRO DR
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-9242
Practice Address - Country:US
Practice Address - Phone:601-939-6442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-09973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist