Healthcare Provider Details

I. General information

NPI: 1396259966
Provider Name (Legal Business Name): SHILOH APOTHECARY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2017
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2049 E SHILOH RD
CORINTH MS
38834-3726
US

IV. Provider business mailing address

2049 E SHILOH RD
CORINTH MS
38834-3726
US

V. Phone/Fax

Practice location:
  • Phone: 662-594-1573
  • Fax: 662-594-1628
Mailing address:
  • Phone: 662-594-1573
  • Fax: 662-594-1628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number16600
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RAYMOND LAFAYETTE MATHIS
Title or Position: PRESIDENT/OWNER
Credential: PHARM.D.
Phone: 662-594-1573