Healthcare Provider Details

I. General information

NPI: 1285639906
Provider Name (Legal Business Name): TYSON DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 S CENTER ST
POTTS CAMP MS
38659-9531
US

IV. Provider business mailing address

41 S CENTER ST
POTTS CAMP MS
38659-9531
US

V. Phone/Fax

Practice location:
  • Phone: 662-333-7782
  • Fax: 662-333-4095
Mailing address:
  • Phone: 662-333-7782
  • Fax: 662-333-4095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number02436/01.1
License Number StateMS

VIII. Authorized Official

Name: ROBERT LOMENICK
Title or Position: OWNER
Credential:
Phone: 662-252-2321