=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023113974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANEYS PHARMACY OF GRENADA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 12/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 1ST ST
-----------------------------------------------------
City | GRENADA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38901-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-226-5232
-----------------------------------------------------
Fax | 662-226-5252
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 100
-----------------------------------------------------
City | GRENADA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38902-0100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JAMES MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-226-5232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 00229010
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------