Healthcare Provider Details

I. General information

NPI: 1194804591
Provider Name (Legal Business Name): MAGIC MART PHARMACY,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2006
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 HIGHWAY 82 E BLDG G
INDIANOLA MS
38751-2325
US

IV. Provider business mailing address

903 HIGHWAY 82 E BLDG G
INDIANOLA MS
38751-2325
US

V. Phone/Fax

Practice location:
  • Phone: 662-887-4135
  • Fax: 662-887-9703
Mailing address:
  • Phone: 662-887-4135
  • Fax: 662-887-9703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number01301
License Number StateMS

VIII. Authorized Official

Name: GUY M MALONE
Title or Position: PRESIDENT
Credential:
Phone: 662-887-4135