Healthcare Provider Details

I. General information

NPI: 1235127226
Provider Name (Legal Business Name): VILLIAGE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 S FOURTH ST
ROLLING FORK MS
39159-5147
US

IV. Provider business mailing address

48 S FOURTH ST
ROLLING FORK MS
39159-5147
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-9020
  • Fax: 662-873-9080
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number03144/01.1
License Number StateMS

VIII. Authorized Official

Name: CASEY PERRY
Title or Position: MANAGER
Credential:
Phone: 662-873-9020