=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063962371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PHARMACY OF QUITMAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2016
-----------------------------------------------------
Last Update Date | 10/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 MAIN ST
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39355-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-776-6282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5105
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39302-5105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-693-2655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID MAJURE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-693-2655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 04508-01FQ
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------