Provider Demographics
NPI:1811068919
Name:OLIVE, PATRICIA M (RPH)
Entity type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:M
Last Name:OLIVE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:PATRICIA
Other - Middle Name:M
Other - Last Name:BACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:73 WINDANCE DR
Mailing Address - Street 2:
Mailing Address - City:CARRIERE
Mailing Address - State:MS
Mailing Address - Zip Code:39426-7946
Mailing Address - Country:US
Mailing Address - Phone:601-799-1889
Mailing Address - Fax:
Practice Address - Street 1:801 HIGHWAY 11 S
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5382
Practice Address - Country:US
Practice Address - Phone:601-798-4771
Practice Address - Fax:601-798-6130
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist