Healthcare Provider Details

I. General information

NPI: 1972685097
Provider Name (Legal Business Name): CONTROLEX ENTRPRISES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 INGALLS AVE
PASCAGOULA MS
39567-5650
US

IV. Provider business mailing address

PO BOX 2070
PASCAGOULA MS
39569-2070
US

V. Phone/Fax

Practice location:
  • Phone: 228-762-4622
  • Fax: 228-762-1756
Mailing address:
  • Phone: 228-762-4622
  • Fax: 228-762-1756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number01128/01.2
License Number StateMS

VIII. Authorized Official

Name: MS. MODENA S CANNON
Title or Position: PHARMACY OPERATIONS MANAGER
Credential:
Phone: 228-769-7067