Provider Demographics
NPI:1306469515
Name:GILMORE, GEORGE DAVID (RPH)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:DAVID
Last Name:GILMORE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:GEORGE
Other - Middle Name:DAVID
Other - Last Name:GILMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:2801 W MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-3001
Mailing Address - Country:US
Mailing Address - Phone:662-816-2522
Mailing Address - Fax:662-840-1676
Practice Address - Street 1:2801 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-3001
Practice Address - Country:US
Practice Address - Phone:662-620-6400
Practice Address - Fax:662-840-1676
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-6595183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00229523Medicaid