Healthcare Provider Details

I. General information

NPI: 1629455431
Provider Name (Legal Business Name): OKOLONA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W MAIN ST
OKOLONA MS
38860-1425
US

IV. Provider business mailing address

210 W MAIN ST
OKOLONA MS
38860-1425
US

V. Phone/Fax

Practice location:
  • Phone: 662-447-0300
  • Fax: 662-447-0130
Mailing address:
  • Phone: 662-447-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number14335/1.1
License Number StateMS

VIII. Authorized Official

Name: TONY SMITH
Title or Position: OWNER
Credential:
Phone: 901-831-8669