Provider Demographics
NPI:1720896202
Name:PUGH, OLIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:PUGH
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 1:123 FITZHUGH ST
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756-3309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7026
Practice Address - Country:US
Practice Address - Phone:662-335-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-101728183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist