Healthcare Provider Details

I. General information

NPI: 1841623808
Provider Name (Legal Business Name): GEORGE COUNTY PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 RATLIFF ST
LUCEDALE MS
39452-6537
US

IV. Provider business mailing address

92 RATLIFF ST
LUCEDALE MS
39452-6537
US

V. Phone/Fax

Practice location:
  • Phone: 601-673-6181
  • Fax: 601-766-4293
Mailing address:
  • Phone: 601-673-6181
  • Fax: 601-766-4293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number12325/2.6
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CARMAN WALLEY
Title or Position: DOP
Credential:
Phone: 601-673-6181