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General NPI Number Information
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NPI Number | 1710644364
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Entity Type | Organization
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Legal Business Name | GULFPORT DISCOUNT DRUGS
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Dates
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Enumeration Date | 11/18/2021
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Last Update Date | 11/18/2021
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Provider Practice Location Address
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Address Line | 1105 BROAD AVE
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City | GULFPORT
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State | MS
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Zip | 39501-2415
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Country | US
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Telephone | 228-424-5579
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Fax |
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Provider Business Mailing Address
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Address Line | 13326 MARYS WAY
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City | DIBERVILLE
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State | MS
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Zip | 39540-6610
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Country | US
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Telephone | 228-424-5579
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Fax |
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Authorized Official
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Title or Position | PHARMACIST
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Name | DR. STEVE LARRY WILSON JR.
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Credential | PHARMD
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Telephone | 228-424-5579
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail 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 | 183500000X
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Taxonomy Name | Pharmacist
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License Number |
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License Number State |
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