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General NPI Number Information
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NPI Number | 1043304033
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Entity Type | Organization
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Legal Business Name | MEDI MART PHARMACIES OF MISSISSIPPI, INC.
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3737 MAIN ST
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City | MOSS POINT
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State | MS
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Zip | 39563-5107
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Country | US
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Telephone | 228-474-1011
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Fax | 228-474-1033
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Provider Business Mailing Address
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Address Line | 3737 MAIN ST
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City | MOSS POINT
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State | MS
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Zip | 39563-5107
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Country | US
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Telephone | 228-474-1011
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Fax | 228-474-1033
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. CLARENCE E. DUBOSE SR.
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Credential | R.PH.
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Telephone | 228-474-1011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 01148/01.1
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License Number State | MS
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