=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922027622
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PICAYUNE DRUG CO., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 12/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 HIGHWAY 11 N
-----------------------------------------------------
City | PICAYUNE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39466-3312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-798-4846
-----------------------------------------------------
Fax | 601-798-4825
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 HIGHWAY 11 N P.O. BOX 10
-----------------------------------------------------
City | PICAYUNE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39466-3312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-798-4846
-----------------------------------------------------
Fax | 601-798-4825
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ANDREW L. FAILLA
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 601-798-4846
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 00937/01.1
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------