Healthcare Provider Details

I. General information

NPI: 1407969660
Provider Name (Legal Business Name): YVONNE G. MARASCALCO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 11/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 SUNSET DRIVE SUITE C
GRENADA MS
38901
US

IV. Provider business mailing address

1300 SUNSET DRIVE SUITE C
GRENADA MS
38901
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-0666
  • Fax: 662-226-1718
Mailing address:
  • Phone: 662-226-0666
  • Fax: 662-226-1718

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: YVONNE G MARASCALCO
Title or Position: OWNER
Credential:
Phone: 662-230-1940