Provider Demographics
NPI:1831195593
Name:HENRY, RONALD A (RPH)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:A
Last Name:HENRY
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:P.O. BOX 4361
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-4361
Mailing Address - Country:US
Mailing Address - Phone:601-425-3033
Mailing Address - Fax:601-422-0291
Practice Address - Street 1:117 SOUTH 11TH AVENUE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4312
Practice Address - Country:US
Practice Address - Phone:601-425-3033
Practice Address - Fax:601-422-0291
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07318183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030565Medicaid