Provider Demographics
NPI:1770925604
Name:SMITH, ALISA B (RPH)
Entity type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:B
Last Name:SMITH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:BUDE
Mailing Address - State:MS
Mailing Address - Zip Code:39630-0129
Mailing Address - Country:US
Mailing Address - Phone:601-384-2383
Mailing Address - Fax:601-384-1650
Practice Address - Street 1:100 MAIN ST N
Practice Address - Street 2:
Practice Address - City:BUDE
Practice Address - State:MS
Practice Address - Zip Code:39630-7117
Practice Address - Country:US
Practice Address - Phone:601-384-2383
Practice Address - Fax:601-384-1650
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08383183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist