Healthcare Provider Details

I. General information

NPI: 1205175031
Provider Name (Legal Business Name): PICAYUNE DRUG CO. NORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2013
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3310 HIGHWAY 11 N
PICAYUNE MS
39466-2000
US

IV. Provider business mailing address

3310 HIGHWAY 11 N
PICAYUNE MS
39466-2000
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 Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. ANDREW L. FAILLA
Title or Position: PRESIDENT
Credential: R.PH
Phone: 601-273-0042