Healthcare Provider Details

I. General information

NPI: 1821190463
Provider Name (Legal Business Name): MKB PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 03/07/2023
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12372 HIGHWAY 49
GULFPORT MS
39503-2741
US

IV. Provider business mailing address

12372 HIGHWAY 49
GULFPORT MS
39503-2741
US

V. Phone/Fax

Practice location:
  • Phone: 228-832-1414
  • Fax: 228-832-1479
Mailing address:
  • Phone: 228-832-1414
  • Fax: 228-832-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number02829/01.1
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN FRANCIS PISARICH
Title or Position: PRESIDENT
Credential: PHARM.D.
Phone: 228-832-1414