Healthcare Provider Details

I. General information

NPI: 1811906357
Provider Name (Legal Business Name): RICK QUINN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 ALCORN DR
CORINTH MS
38834-9392
US

IV. Provider business mailing address

504 ALCORN DR
CORINTH MS
38834-9392
US

V. Phone/Fax

Practice location:
  • Phone: 662-286-5747
  • Fax: 662-286-5508
Mailing address:
  • Phone: 662-286-5747
  • Fax: 662-286-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number03051/01.1
License Number StateMS

VIII. Authorized Official

Name: MS. AMANDA ANN KETCHUM
Title or Position: CHIEF PHARMACIST
Credential: R.PH.
Phone: 662-286-5747