Provider Demographics
NPI:1619396892
Name:COMPLETE DIABETES PHARMACY CARE INC
Entity Type:Organization
Organization Name:COMPLETE DIABETES PHARMACY CARE INC
Other - Org Name:COMPLETE DIABETES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:BROSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-646-3255
Mailing Address - Street 1:7165 SWINNEA RD
Mailing Address - Street 2:BUILDING B-2
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6360
Mailing Address - Country:US
Mailing Address - Phone:662-280-5533
Mailing Address - Fax:800-208-0863
Practice Address - Street 1:7165 SWINNEA RD
Practice Address - Street 2:BLDG B-2
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6360
Practice Address - Country:US
Practice Address - Phone:662-280-5533
Practice Address - Fax:800-208-0863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS133403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145616OtherPK