Healthcare Provider Details

I. General information

NPI: 1003646951
Provider Name (Legal Business Name): COASTAL FAMILY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 CENTRAL AVE E
WIGGINS MS
39577-9611
US

IV. Provider business mailing address

10467 CORPORATE DR
GULFPORT MS
39503-4634
US

V. Phone/Fax

Practice location:
  • Phone: 601-385-0077
  • Fax: 601-385-0078
Mailing address:
  • Phone: 228-374-2494
  • Fax: 228-396-3457

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: PATRICK HUTTO
Title or Position: DIRECTOR OF PHARMACY SERVICES
Credential:
Phone: 228-374-2476