Provider Demographics
NPI:1801488846
Name:LANE, ALLEN ELLIOTT (RPH)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:ELLIOTT
Last Name:LANE
Suffix:
Gender:M
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 8647
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39562-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4931 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-2746
Practice Address - Country:US
Practice Address - Phone:228-474-4663
Practice Address - Fax:228-474-5545
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-072281835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care