=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497497960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DHP BROOKHAVEN, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2022
-----------------------------------------------------
Last Update Date | 07/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1037 HIGHWAY 84 E
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39601-8776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-967-8411
-----------------------------------------------------
Fax | 833-481-3378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1037 HIGHWAY 84 E
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39601-8776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-695-0210
-----------------------------------------------------
Fax | 601-756-2001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER/RPH
-----------------------------------------------------
Name | JAMES EARL CRANE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-967-8411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------