Healthcare Provider Details

I. General information

NPI: 1366013179
Provider Name (Legal Business Name): MAGNOLIA DRUG CO., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 HIGHWAY 51 N
BATESVILLE MS
38606-2358
US

IV. Provider business mailing address

131 HIGHWAY 51 N
BATESVILLE MS
38606-2358
US

V. Phone/Fax

Practice location:
  • Phone: 662-487-6268
  • Fax: 662-487-6278
Mailing address:
  • Phone: 662-487-6268
  • Fax: 662-487-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. CRYSTIE SHEREE MOORMAN
Title or Position: PHARMACIST/OWNER
Credential: PHARMD
Phone: 662-487-6268