Healthcare Provider Details

I. General information

NPI: 1912049073
Provider Name (Legal Business Name): FUNDERBURK'S PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 W COMMERCE ST
HERNANDO MS
38632-2240
US

IV. Provider business mailing address

134 W COMMERCE ST
HERNANDO MS
38632-2240
US

V. Phone/Fax

Practice location:
  • Phone: 662-429-5337
  • Fax: 662-429-5207
Mailing address:
  • Phone: 662-429-5337
  • Fax: 662-429-5207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number06916
License Number StateMS

VIII. Authorized Official

Name: MRS. CHERYL M SUDDUTH
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 662-429-5337