Provider Demographics
NPI:1982122289
Name:BRUISTER, CARROLL III
Entity Type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:
Last Name:BRUISTER
Suffix:III
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 1:11850 MS HWY 15
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 MABUS
Practice Address - Street 2:
Practice Address - City:ACKERMAN
Practice Address - State:MS
Practice Address - Zip Code:39735
Practice Address - Country:US
Practice Address - Phone:662-285-6039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE6788183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist