Provider Demographics
NPI:1518350669
Name:DIAMONDHEAD MEDICINE, LLC
Entity Type:Organization
Organization Name:DIAMONDHEAD MEDICINE, LLC
Other - Org Name:DIAMONDHEAD FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:SUMMER
Authorized Official - Last Name:GALLOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-234-6236
Mailing Address - Street 1:20117 BOX CV
Mailing Address - Street 2:
Mailing Address - City:SAUCIER
Mailing Address - State:MS
Mailing Address - Zip Code:39574-8702
Mailing Address - Country:US
Mailing Address - Phone:228-234-6236
Mailing Address - Fax:228-831-9951
Practice Address - Street 1:5439 W ALOHA DR STE D
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3379
Practice Address - Country:US
Practice Address - Phone:228-234-6236
Practice Address - Fax:228-831-9951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS142593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy