Healthcare Provider Details

I. General information

NPI: 1114953726
Provider Name (Legal Business Name): PHARMACY MANAGEMENT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N MAIN ST
WATER VALLEY MS
38965-2905
US

IV. Provider business mailing address

111 N MAIN ST
WATER VALLEY MS
38965-2905
US

V. Phone/Fax

Practice location:
  • Phone: 662-473-1245
  • Fax: 662-473-1247
Mailing address:
  • Phone: 662-327-4025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number07473
License Number StateMS

VIII. Authorized Official

Name: MISTY OSWALT
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 662-327-4025