Provider Demographics
NPI:1174812069
Name:BRENT, WILLIAM E (RPH)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:E
Last Name:BRENT
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 1:984 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1509
Mailing Address - Country:US
Mailing Address - Phone:662-342-1915
Mailing Address - Fax:662-393-4021
Practice Address - Street 1:984 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1509
Practice Address - Country:US
Practice Address - Phone:662-342-1915
Practice Address - Fax:662-393-4021
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-07333183500000X
TN10915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000010915OtherSTATE OF TENNESSEE DEPARTMENT OF HEALTH, PHARMACIST LICENSE NUMBER
MSE-07333OtherMISSISSIPPI PHARMACY LICENSE NUMBER