Provider Demographics
NPI:1679507644
Name:WAVELAND PHARMACY LLC
Entity Type:Organization
Organization Name:WAVELAND PHARMACY LLC
Other - Org Name:WAVELAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHCST
Authorized Official - Prefix:
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LETELLIER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:228-463-1055
Mailing Address - Street 1:PO BOX 4617
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39521-4617
Mailing Address - Country:US
Mailing Address - Phone:228-463-1055
Mailing Address - Fax:
Practice Address - Street 1:112 AUDERER BLVD
Practice Address - Street 2:
Practice Address - City:WAVELAND
Practice Address - State:MS
Practice Address - Zip Code:39576-2432
Practice Address - Country:US
Practice Address - Phone:228-463-1055
Practice Address - Fax:228-463-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MSF053523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2046344OtherPK
MS00330669Medicaid
MS00330669Medicaid
MS01403043Medicaid