Healthcare Provider Details

I. General information

NPI: 1285715037
Provider Name (Legal Business Name): BACK BAY DRUGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10437 LAMEY BRIDGE RD SUITE A
DIBERVILLE MS
39540-2709
US

IV. Provider business mailing address

10437 LAMEY BRIDGE RD SUITE A
DIBERVILLE MS
39540-2709
US

V. Phone/Fax

Practice location:
  • Phone: 228-396-2228
  • Fax: 228-396-2257
Mailing address:
  • Phone: 228-396-2228
  • Fax: 228-396-2257

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: MR. WILLIAM T AYCOCK
Title or Position: PHARMACIST
Credential: R.PH.
Phone: 228-396-2257