Healthcare Provider Details

I. General information

NPI: 1710644364
Provider Name (Legal Business Name): GULFPORT DISCOUNT DRUGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 BROAD AVE
GULFPORT MS
39501-2415
US

IV. Provider business mailing address

13326 MARYS WAY
DIBERVILLE MS
39540-6610
US

V. Phone/Fax

Practice location:
  • Phone: 228-424-5579
  • Fax:
Mailing address:
  • Phone: 228-424-5579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVE LARRY WILSON JR.
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 228-424-5579