Provider Demographics
NPI:1306298633
Name:CHILDERS, CODY MICHAEL (PHARM D)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:MICHAEL
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 MULLHERRIN DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-4534
Mailing Address - Country:US
Mailing Address - Phone:901-482-1689
Mailing Address - Fax:
Practice Address - Street 1:6745 S SIWELL RD
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-8747
Practice Address - Country:US
Practice Address - Phone:601-863-2004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-14467183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist