Healthcare Provider Details

I. General information

NPI: 1023614724
Provider Name (Legal Business Name): NORTHTOWN PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6220 OLD CANTON RD
JACKSON MS
39211-2924
US

IV. Provider business mailing address

6220 OLD CANTON RD
JACKSON MS
39211-2924
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4694
  • Fax: 769-333-9173
Mailing address:
  • Phone: 601-665-4694
  • Fax: 769-333-9173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW CLARK
Title or Position: CEO/FOUNDER
Credential: PHARM. D
Phone: 601-665-4694