=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669794145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUITMAN DRUGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2010
-----------------------------------------------------
Last Update Date | 02/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 N ARCHUSA AVE
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39355-2416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-776-2146
-----------------------------------------------------
Fax | 601-776-5752
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39355-0003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ALLEN W VOWELL JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-776-2146
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 01354/01.1
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------