Provider Demographics
NPI:1205353885
Name:REVES, DENNIS RAY
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:RAY
Last Name:REVES
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 1:218 SUNSET CIR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7003
Mailing Address - Country:US
Mailing Address - Phone:601-856-4504
Mailing Address - Fax:
Practice Address - Street 1:229 N UNION ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-3728
Practice Address - Country:US
Practice Address - Phone:601-859-4681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07131183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist