Healthcare Provider Details

I. General information

NPI: 1902454523
Provider Name (Legal Business Name): PANOLA PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 HIGHWAY 6 E
BATESVILLE MS
38606-3000
US

IV. Provider business mailing address

440 HIGHWAY 6 E
BATESVILLE MS
38606-3000
US

V. Phone/Fax

Practice location:
  • Phone: 662-855-1204
  • Fax: 662-855-1218
Mailing address:
  • Phone: 662-934-3039
  • Fax:

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: JENNIFER SULLIVANT
Title or Position: VICE PRESIDENT/OWNER
Credential:
Phone: 662-934-3039