1063178051 NPI number — DR. PEYTON SARAELIZABETH BLACK PHARMD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063178051 NPI number — DR. PEYTON SARAELIZABETH BLACK PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
PEYTON
Provider Middle Name:
SARAELIZABETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063178051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 WEST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERNANDO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38632-2114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-421-9252
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5055 STAGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38128-5033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-266-5130
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  46766 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: E-100413 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com