Healthcare Provider Details

I. General information

NPI: 1578955381
Provider Name (Legal Business Name): UPTOWN PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 GLUCKSTADT RD SUITE D
MADISON MS
39110-6981
US

IV. Provider business mailing address

119 PLANTERS ROW
MADISON MS
39110-7990
US

V. Phone/Fax

Practice location:
  • Phone: 601-631-1667
  • Fax:
Mailing address:
  • Phone: 601-631-1667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number14250
License Number StateMS

VIII. Authorized Official

Name: DR. JIMMY D YAWN II
Title or Position: PHARMACIST
Credential: PHARMD
Phone: 601-631-1667