Provider Demographics
NPI:1255474102
Name:THIRTEENTH AVENUE PHARMACY
Entity Type:Organization
Organization Name:THIRTEENTH AVENUE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWENER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:MAULDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-428-7257
Mailing Address - Street 1:216 S 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4226
Mailing Address - Country:US
Mailing Address - Phone:601-428-7257
Mailing Address - Fax:601-428-0074
Practice Address - Street 1:216 S 13TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4226
Practice Address - Country:US
Practice Address - Phone:601-428-7257
Practice Address - Fax:601-428-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01527 01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy