=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104998269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMAKAN, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1042A RIVER OAKS DR
-----------------------------------------------------
City | FLOWOOD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39232-9594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-932-6245
-----------------------------------------------------
Fax | 601-939-8286
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1042A RIVER OAKS DR
-----------------------------------------------------
City | FLOWOOD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39232-9594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-932-6245
-----------------------------------------------------
Fax | 601-939-8286
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RONNIE BAGWELL JR.
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 601-932-6245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336I0012X
-----------------------------------------------------
Taxonomy Name | Institutional Pharmacy
-----------------------------------------------------
License Number | 0218002.0
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------