Provider Demographics
NPI:1316954001
Name:EZE, ATHELIA BALAMS (PHARMD)
Entity type:Individual
Prefix:DR
First Name:ATHELIA
Middle Name:BALAMS
Last Name:EZE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 STRANGE RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2539
Mailing Address - Country:US
Mailing Address - Phone:662-323-3503
Mailing Address - Fax:662-323-4409
Practice Address - Street 1:105 STRANGE RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2539
Practice Address - Country:US
Practice Address - Phone:662-323-5033
Practice Address - Fax:662-323-4409
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-09285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07064/01.1OtherRETALIL COMMUNITY PHARMCY