Provider Demographics
NPI:1568513711
Name:PROFESSIONAL PHARMACY, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL PHARMACY, INC.
Other - Org Name:PROFESSIONAL PHARMACY OF TYLERTOWN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-876-2487
Mailing Address - Street 1:201 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-2019
Mailing Address - Country:US
Mailing Address - Phone:601-876-2487
Mailing Address - Fax:601-876-0222
Practice Address - Street 1:201 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2019
Practice Address - Country:US
Practice Address - Phone:601-876-2487
Practice Address - Fax:601-876-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS02151 01.1333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030104Medicaid