Basic Information
| Provider Information | |||||||||
| NPI: | 1629707476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | ODOM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5112 FERN ST | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395671006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2286278898 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2809 DENNY AVE | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288095000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2022 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | T-100168 | MS | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.