Provider Demographics
NPI:1215195045
Name:G AND M PHARMACY
Entity Type:Organization
Organization Name:G AND M PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPHT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:ROBERTSON
Authorized Official - Last Name:WAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-236-2222
Mailing Address - Street 1:2159 S LAMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5223
Mailing Address - Country:US
Mailing Address - Phone:662-236-2222
Mailing Address - Fax:662-236-2213
Practice Address - Street 1:2159 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5223
Practice Address - Country:US
Practice Address - Phone:662-236-2222
Practice Address - Fax:662-236-2213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13861GO332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440904Medicaid