Healthcare Provider Details

I. General information

NPI: 1922544865
Provider Name (Legal Business Name): DVC PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 EARL FRYE BLVD SUITE #1
AMORY MS
38821-5519
US

IV. Provider business mailing address

PO BOX 511
AMORY MS
38821-0511
US

V. Phone/Fax

Practice location:
  • Phone: 662-257-2357
  • Fax: 662-257-2399
Mailing address:
  • Phone: 662-257-2357
  • Fax: 662-257-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number15100
License Number StateMS

VIII. Authorized Official

Name: LISA STODDARD
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-513-6600