Provider Demographics
NPI:1710644364
Name:GULFPORT DISCOUNT DRUGS
Entity Type:Organization
Organization Name:GULFPORT DISCOUNT DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:228-424-5579
Mailing Address - Street 1:13326 MARYS WAY
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-6610
Mailing Address - Country:US
Mailing Address - Phone:228-424-5579
Mailing Address - Fax:
Practice Address - Street 1:1105 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2415
Practice Address - Country:US
Practice Address - Phone:228-424-5579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty