Healthcare Provider Details

I. General information

NPI: 1285987461
Provider Name (Legal Business Name): SOUTHWEST PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 W CONGRESS ST
BROOKHAVEN MS
39601-2603
US

IV. Provider business mailing address

312 MARION AVE
MCCOMB MS
39648-2708
US

V. Phone/Fax

Practice location:
  • Phone: 601-684-4127
  • Fax: 601-684-8479
Mailing address:
  • Phone: 601-684-4127
  • Fax: 601-684-8479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number11696/1.1
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number11696/1.1
License Number StateMS

VIII. Authorized Official

Name: MR. JOE KEITH GUY
Title or Position: PRESIDENT
Credential: RPH
Phone: 601-684-4127