=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508963430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENATOBIA CITY DRUG CO INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 11/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 NORFLEET DR
-----------------------------------------------------
City | SENATOBIA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38668-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-562-8042
-----------------------------------------------------
Fax | 662-562-0644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 NORFLEET DR
-----------------------------------------------------
City | SENATOBIA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38668-2220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LYNN BARHAM
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 662-562-8042
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 00121011
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------