Provider Demographics
NPI:1962791178
Name:TIGRETT, WAYMON
Entity type:Individual
Prefix:
First Name:WAYMON
Middle Name:
Last Name:TIGRETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N COLLEGE ST
Mailing Address - Street 2:SUITE 101 BOX 9
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-4437
Mailing Address - Country:US
Mailing Address - Phone:601-573-7788
Mailing Address - Fax:
Practice Address - Street 1:201 N COLLEGE ST
Practice Address - Street 2:SUITE 101 BOX 9
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-4437
Practice Address - Country:US
Practice Address - Phone:601-573-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR-5220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist