Provider Demographics
NPI:1487244802
Name:REA, GEORGE ROBERT (RPH)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:ROBERT
Last Name:REA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11765 HIGHWAY 35 N
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-4870
Mailing Address - Country:US
Mailing Address - Phone:601-650-8838
Mailing Address - Fax:
Practice Address - Street 1:108 HIGHWAY 12 E
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3304
Practice Address - Country:US
Practice Address - Phone:662-289-1963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-06345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty