Healthcare Provider Details

I. General information

NPI: 1689601957
Provider Name (Legal Business Name): PICAYUNE DRUG CO., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 04/12/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HIGHWAY 11 N
PICAYUNE MS
39466-3312
US

IV. Provider business mailing address

PO BOX 10
PICAYUNE MS
39466-0010
US

V. Phone/Fax

Practice location:
  • Phone: 601-798-4846
  • Fax: 601-798-4825
Mailing address:
  • Phone: 601-798-4846
  • Fax: 601-798-4825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number055-05477-9
License Number StateMS

VIII. Authorized Official

Name: MR. ANDREW L FAILLA
Title or Position: PRESIDENT
Credential: R PH
Phone: 601-798-4846