Healthcare Provider Details

I. General information

NPI: 1912918558
Provider Name (Legal Business Name): GENE POLKS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 SIMPSON HIGHWAY 149
MAGEE MS
39111-3416
US

IV. Provider business mailing address

406 SIMPSON HIGHWAY 149
MAGEE MS
39111-3416
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-2532
  • Fax: 601-849-2558
Mailing address:
  • Phone: 601-849-2532
  • Fax: 601-849-2558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number00445/1.1
License Number StateMS

VIII. Authorized Official

Name: BRINSON POLK
Title or Position: OWNER
Credential: RPH
Phone: 601-849-2533