=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588042477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS STREET APOTHECARY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2015
-----------------------------------------------------
Last Update Date | 05/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 86 S THOMAS ST
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38801-4355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-678-3330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 86 S THOMAS ST
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38801-4355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-678-3330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JAMES MARC GUNNELLS
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 662-678-3330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------