Healthcare Provider Details

I. General information

NPI: 1295373165
Provider Name (Legal Business Name): CEFALU RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16575 W MAIN ST
LOUISVILLE MS
39339
US

IV. Provider business mailing address

16575 W MAIN ST
LOUISVILLE MS
39339
US

V. Phone/Fax

Practice location:
  • Phone: 662-773-5363
  • Fax: 662-773-9951
Mailing address:
  • Phone: 662-773-5363
  • Fax: 662-773-9951

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: THOMAS CEFALU
Title or Position: VP, PHARMACIST
Credential:
Phone: 662-773-5363