Provider Demographics
NPI:1316037237
Name:TUNICA PHARMACY, INC.
Entity Type:Organization
Organization Name:TUNICA PHARMACY, INC.
Other - Org Name:TUNICA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:POFF
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:901-826-6493
Mailing Address - Street 1:PO BOX 1724
Mailing Address - Street 2:
Mailing Address - City:TUNICA
Mailing Address - State:MS
Mailing Address - Zip Code:38676-1724
Mailing Address - Country:US
Mailing Address - Phone:662-363-1431
Mailing Address - Fax:663-363-9966
Practice Address - Street 1:1337 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:TUNICA
Practice Address - State:MS
Practice Address - Zip Code:38676-9661
Practice Address - Country:US
Practice Address - Phone:662-363-1431
Practice Address - Fax:662-363-9966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
MS006533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2043432OtherPK
MS00034711Medicaid
MS000034711Medicaid