Healthcare Provider Details

I. General information

NPI: 1376628792
Provider Name (Legal Business Name): CONTROLEX ENTERPRISES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2307 HIGHWAY 90
GAUTIER MS
39553-5231
US

IV. Provider business mailing address

1420 INGALLS AVE
PASCAGOULA MS
39567-5650
US

V. Phone/Fax

Practice location:
  • Phone: 228-497-4090
  • Fax: 228-762-1756
Mailing address:
  • Phone: 228-769-7067
  • Fax: 228-762-1756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number00839/01.2
License Number StateMS

VIII. Authorized Official

Name: MS. MODENA S CANNON
Title or Position: PHARMACY OPERATIONS MANAGER
Credential:
Phone: 228-769-7067