Provider Demographics
NPI:1629235882
Name:ADVANTAGE PHARMACY
Entity Type:Organization
Organization Name:ADVANTAGE PHARMACY
Other - Org Name:ADVANTAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANG PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:BEACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-268-1422
Mailing Address - Street 1:6375 U S HIGHWAY 98
Mailing Address - Street 2:SUITE 50
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-7410
Mailing Address - Country:US
Mailing Address - Phone:601-268-1422
Mailing Address - Fax:601-268-1424
Practice Address - Street 1:6375 U S HIGHWAY 98
Practice Address - Street 2:SUITE 50
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-7410
Practice Address - Country:US
Practice Address - Phone:601-268-1422
Practice Address - Fax:601-268-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS077260113336C0003X
3336C0004X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2047542OtherPK