Healthcare Provider Details

I. General information

NPI: 1003436569
Provider Name (Legal Business Name): MOSBYS DRUG STORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E PEACE ST
CANTON MS
39046-4937
US

IV. Provider business mailing address

195 E PEACE ST
CANTON MS
39046-4519
US

V. Phone/Fax

Practice location:
  • Phone: 601-859-4212
  • Fax: 601-859-4260
Mailing address:
  • Phone: 601-859-4212
  • Fax: 601-859-4260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL C MURPHY
Title or Position: OWNER/MEMBER
Credential: BS
Phone: 601-859-3939