Provider Demographics
NPI:1952905135
Name:MYERS, MITCHELL BRENT
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:BRENT
Last Name:MYERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8304
Mailing Address - Country:US
Mailing Address - Phone:601-856-2021
Mailing Address - Fax:601-856-2061
Practice Address - Street 1:1014 HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8304
Practice Address - Country:US
Practice Address - Phone:601-856-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19264183500000X
COPHA.0021188183500000X
FLPS54560183500000X
LAPST.021374183500000X
TN39898183500000X
TX50026183500000X
MST-14186183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00888740Medicaid