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General NPI Number Information
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NPI Number | 1619396892
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Entity Type | Organization
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Legal Business Name | COMPLETE DIABETES PHARMACY CARE INC
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Dates
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Enumeration Date | 04/15/2014
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Last Update Date | 11/11/2022
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Provider Practice Location Address
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Address Line | 7165 SWINNEA RD BLDG B-2
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City | SOUTHAVEN
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State | MS
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Zip | 38671-6360
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Country | US
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Telephone | 662-280-5533
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Fax | 800-208-0863
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Provider Business Mailing Address
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Address Line | 7165 SWINNEA RD BUILDING B-2
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City | SOUTHAVEN
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State | MS
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Zip | 38671-6360
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Country | US
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Telephone | 662-280-5533
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Fax | 800-208-0863
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Authorized Official
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Title or Position | SECRETARY
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Name | CRAIG BROSSEAU
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Credential |
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Telephone | 952-646-3255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 13340
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License Number State | MS
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