Healthcare Provider Details

I. General information

NPI: 1073524583
Provider Name (Legal Business Name): EMMANUEL RIDGE COMM PHCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2073 HIGHWAY 49 S
FLORENCE MS
39073-9422
US

IV. Provider business mailing address

PO BOX 1522
FLORENCE MS
39073-1522
US

V. Phone/Fax

Practice location:
  • Phone: 601-845-3544
  • Fax: 601-845-3636
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number06939011
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BEATRICE EZEM
Title or Position: PRESIDENT
Credential: RN CM CLNC
Phone: 601-927-9839