Healthcare Provider Details

I. General information

NPI: 1336192939
Provider Name (Legal Business Name): APS PHARMACY 801 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 AIRPORT INDUSTRIAL DR
SOUTHAVEN MS
38671-5870
US

IV. Provider business mailing address

480 AIRPORT INDUSTRIAL DR
SOUTHAVEN MS
38671-5870
US

V. Phone/Fax

Practice location:
  • Phone: 662-536-0384
  • Fax: 662-536-4207
Mailing address:
  • Phone: 662-536-0384
  • Fax: 662-536-4207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number0595626
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARK BRADFORD
Title or Position: PRESIDENT
Credential:
Phone: 662-536-0384