Healthcare Provider Details

I. General information

NPI: 1457479438
Provider Name (Legal Business Name): TAYLOR HARRIS DRUG STORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 30TH AVE
GULFPORT MS
39501-4534
US

IV. Provider business mailing address

1908 30TH AVE
GULFPORT MS
39501-4534
US

V. Phone/Fax

Practice location:
  • Phone: 228-868-1036
  • Fax: 228-868-1355
Mailing address:
  • Phone: 228-868-1036
  • Fax: 228-868-1355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateMS

VIII. Authorized Official

Name: MR. MACK BENNIE HARRIS
Title or Position: CO-OWNER PHARMACIST
Credential: R.PH.
Phone: 228-868-1036