Provider Demographics
NPI:1821821661
Name:SISTRUNK, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:SISTRUNK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8066 OLD HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631-3874
Mailing Address - Country:US
Mailing Address - Phone:318-658-4902
Mailing Address - Fax:
Practice Address - Street 1:616 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:MS
Practice Address - Zip Code:39669-9706
Practice Address - Country:US
Practice Address - Phone:601-888-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.024961183500000X
MSE-101205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist