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General NPI Number Information
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NPI Number | 1114373586
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Entity Type | Organization
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Legal Business Name | GENTEX PHARMA
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Dates
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Enumeration Date | 05/04/2016
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Last Update Date | 05/04/2016
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Provider Practice Location Address
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Address Line | 121 MARKETRIDGE DR SUITE C
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City | RIDGELAND
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State | MS
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Zip | 39157-6027
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Country | US
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Telephone | 601-990-9497
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Fax | 601-510-9318
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Provider Business Mailing Address
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Address Line | 121 MARKETRIDGE DR SUITE C
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City | RIDGELAND
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State | MS
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Zip | 39157-6027
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Country | US
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Telephone | 601-990-9497
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Fax | 601-510-9318
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Authorized Official
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Title or Position | OWNER
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Name | FORD JENNINGS MUNDY
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Credential | PERSON IN CHARGE
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Telephone | 870-243-1687
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | 06677/6.1
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License Number State | MS
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