Healthcare Provider Details

I. General information

NPI: 1306325402
Provider Name (Legal Business Name): FAMILY DRUG MART OF POPLARVILLE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 12/24/2021
Certification Date: 12/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HIGHWAY 11 N
POPLARVILLE MS
39470-2217
US

IV. Provider business mailing address

2299 SUNSET BLVD
SLIDELL LA
70461-5605
US

V. Phone/Fax

Practice location:
  • Phone: 504-338-7992
  • Fax: 985-727-7494
Mailing address:
  • Phone: 504-338-7992
  • Fax: 985-727-7494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number17206
License Number StateMS

VIII. Authorized Official

Name: MR. JOSE MIGUEL YANEZ
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 504-338-7992