Provider Demographics
NPI:1194485250
Name:MCNULTY, COLLEEN J
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:J
Last Name:MCNULTY
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 1:831 CEDAR LAKE RD APT 1310
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-4660
Mailing Address - Country:US
Mailing Address - Phone:228-239-0183
Mailing Address - Fax:
Practice Address - Street 1:12007 LAMEY BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-8907
Practice Address - Country:US
Practice Address - Phone:228-392-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE100320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist