Healthcare Provider Details

I. General information

NPI: 1922087493
Provider Name (Legal Business Name): SMITHVILLE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63432 HIGHWAY 25 N
SMITHVILLE MS
38870-7763
US

IV. Provider business mailing address

63432 HIGHWAY 25 N
SMITHVILLE MS
38870-7763
US

V. Phone/Fax

Practice location:
  • Phone: 662-651-5377
  • Fax: 662-651-5379
Mailing address:
  • Phone: 662-651-5377
  • Fax: 662-651-5379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number04541/01.1
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberCS-04541/01.1
License Number StateMS

VIII. Authorized Official

Name: S. PHILLIP CARSON
Title or Position: PRESIDENT
Credential: R. PH
Phone: 662-651-5377