Healthcare Provider Details

I. General information

NPI: 1205080975
Provider Name (Legal Business Name): GRENADA PHARMNET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 11/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 W MONROE ST
GRENADA MS
38901-5227
US

IV. Provider business mailing address

403 SUMMIT ST
WINONA MS
38967-2113
US

V. Phone/Fax

Practice location:
  • Phone: 662-294-1111
  • Fax:
Mailing address:
  • Phone: 662-283-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number07944/02.0
License Number StateMS

VIII. Authorized Official

Name: MISS NATALIE MAINELLI
Title or Position: PHARMACY MANAGER
Credential: RPH.
Phone: 662-294-1111