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General NPI Number Information
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NPI Number | 1255474102
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Entity Type | Organization
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Legal Business Name | THIRTEENTH AVENUE PHARMACY
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Dates
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Enumeration Date | 02/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 216 S 13TH AVE
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City | LAUREL
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State | MS
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Zip | 39440-4226
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Country | US
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Telephone | 601-428-7257
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Fax | 601-428-0074
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Provider Business Mailing Address
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Address Line | 216 S 13TH AVE
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City | LAUREL
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State | MS
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Zip | 39440-4226
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Country | US
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Telephone | 601-428-7257
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Fax | 601-428-0074
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Authorized Official
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Title or Position | PHARMACIST OWENER
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Name | KYLE AARON MAULDIN
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Credential |
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Telephone | 601-428-7257
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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 | 01527 01.1
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License Number State | MS
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