Provider Demographics
NPI:1578603015
Name:WALNUT SQUARE PHARMACY LLC
Entity Type:Organization
Organization Name:WALNUT SQUARE PHARMACY LLC
Other - Org Name:WALNUT SQUARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WORREL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:601-583-3232
Mailing Address - Street 1:124 WALNUT CIR
Mailing Address - Street 2:STE 3
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 WALNUT CIR
Practice Address - Street 2:STE 3
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3500
Practice Address - Country:US
Practice Address - Phone:601-543-0111
Practice Address - Fax:601-543-0208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS055150113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2521082OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2521082OtherOTHER ID NUMBER
MS0330691Medicaid