Healthcare Provider Details

I. General information

NPI: 1447575394
Provider Name (Legal Business Name): ENTERPRISE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 OLD MILL CREEK RD
ENTERPRISE MS
39330-9649
US

IV. Provider business mailing address

83 OLD MILL CREEK RD
ENTERPRISE MS
39330-9649
US

V. Phone/Fax

Practice location:
  • Phone: 601-659-9909
  • Fax: 601-659-9902
Mailing address:
  • Phone: 601-659-9909
  • Fax: 601-659-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0843211
License Number StateMS

VIII. Authorized Official

Name: DANIEL JOHNSON
Title or Position: OWNER
Credential:
Phone: 601-938-5323