{
"Npi": {
"NPI": "1003207895",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "DIAMONDHEAD HEALTH MART PHARMACY,LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 4258",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "BAY ST LOUIS",
"MailingAddressStateName": "MS",
"MailingAddressPostalCode": "39521-4258",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "228-222-4662",
"MailingAddressFaxNumber": "228-222-4733",
"FirstLinePracticeLocationAddress": "4405 E ALOHA DR # AA",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DIAMONDHEAD",
"PracticeLocationAddressStateName": "MS",
"PracticeLocationAddressPostalCode": "39525-3380",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "228-222-4662",
"PracticeLocationAddressFaxNumber": "228-222-4733",
"EnumerationDate": "02/15/2015",
"LastUpdateDate": "11/30/2021",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "LETELLIER",
"AuthorizedOfficialFirstName": "RUDY",
"AuthorizedOfficialMiddleName": "ALLEN",
"AuthorizedOfficialTitle": "OWNER/PHARMACIST",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "RPH",
"AuthorizedOfficialTelephoneNumber": "228-222-4662",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": "14221/1.1",
"LicenseNumberStateCode": "MS",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}