Healthcare Provider Details

I. General information

NPI: 1124679873
Provider Name (Legal Business Name): FAMILY DRUG MART OF SUMRALL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 12/24/2021
Certification Date: 12/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4233 ROCKY BRANCH RD STE B
SUMRALL MS
39482-4142
US

IV. Provider business mailing address

2299 SUNSET BLVD
SLIDELL LA
70461-5605
US

V. Phone/Fax

Practice location:
  • Phone: 504-338-7992
  • Fax:
Mailing address:
  • Phone: 504-338-7992
  • Fax: 985-265-4550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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