Healthcare Provider Details

I. General information

NPI: 1689453847
Provider Name (Legal Business Name): MADISON BUZICKY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2023
Last Update Date: 09/27/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 SIMPSON US 49
MAGEE MS
39111
US

IV. Provider business mailing address

458 BLACKWELL RD
MENDENHALL MS
39114-5650
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-2628
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-101281
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: