Provider Demographics
NPI:1003507393
Name:GLUCKSTADT PHARMACY LLC
Entity Type:Organization
Organization Name:GLUCKSTADT PHARMACY LLC
Other - Org Name:GLUCKSTADT PHARMACY LTC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-859-3939
Mailing Address - Street 1:195 E PEACE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-4519
Mailing Address - Country:US
Mailing Address - Phone:601-859-3939
Mailing Address - Fax:601-855-2133
Practice Address - Street 1:154 CALHOUN STATION PARKWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:GLUCKSTADT
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-720-2290
Practice Address - Fax:601-790-2292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy