Healthcare Provider Details

I. General information

NPI: 1487577078
Provider Name (Legal Business Name): MALLORY'S MODERN MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/01/2026
Certification Date: 08/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W BANKHEAD ST
NEW ALBANY MS
38652-3314
US

IV. Provider business mailing address

141 W BANKHEAD ST
NEW ALBANY MS
38652-3314
US

V. Phone/Fax

Practice location:
  • Phone: 662-486-2150
  • Fax:
Mailing address:
  • Phone: 662-486-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State

VIII. Authorized Official

Name: MALLORY BEATY
Title or Position: OWNER/COMPOUNDING PHARMACIST
Credential: PHARMD, BCSCP
Phone: 662-316-5021