Healthcare Provider Details

I. General information

NPI: 1649820390
Provider Name (Legal Business Name): MANDALYN MCCULLOUGH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 MOUNT PLEASANT RD
HERNANDO MS
38632-1909
US

IV. Provider business mailing address

4722 PLEASANT BREEZE DR
OLIVE BRANCH MS
38654-0025
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-5327
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-13134
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number37530
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: