Individual
MR. KENNERH PROVINE COLLINS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
BS
Contact information
Practice address
2917 56TH COURT, MERIDIAN, MS 39305
(601) 604-9114
Mailing address
2917 56TH COURT, MERIDIAN, MS 39305
(601) 604-9114
Taxonomy
Speciality
Code
Description
License number
State
1835P1200X
Pharmacotherapy Pharmacist
Primary
E7052
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
E7052
MISSISSIPPI PHARMACY LICENSE
MS
Enumeration date
06/10/2013
Last updated
06/10/2013
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