Provider Demographics
NPI:1811990732
Name:BLUE, WENDY HAYDEL (PT PHARM D)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:HAYDEL
Last Name:BLUE
Suffix:
Gender:F
Credentials:PT PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:300 RAWLS DR
Mailing Address - Street 2:STE 700A
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2872
Mailing Address - Country:US
Mailing Address - Phone:601-684-0355
Mailing Address - Fax:601-250-0476
Practice Address - Street 1:300 RAWLS DR
Practice Address - Street 2:STE 700A
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2872
Practice Address - Country:US
Practice Address - Phone:601-684-0355
Practice Address - Fax:601-250-0476
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS650000089Medicare PIN