=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003207895
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAMONDHEAD HEALTH MART PHARMACY,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2015
-----------------------------------------------------
Last Update Date | 11/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4405 E ALOHA DR # AA
-----------------------------------------------------
City | DIAMONDHEAD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39525-3380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-222-4662
-----------------------------------------------------
Fax | 228-222-4733
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4258
-----------------------------------------------------
City | BAY ST LOUIS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39521-4258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-222-4662
-----------------------------------------------------
Fax | 228-222-4733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHARMACIST
-----------------------------------------------------
Name | MR. RUDY ALLEN LETELLIER
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 228-222-4662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 14221/1.1
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------