Provider Demographics
NPI:1750327136
Name:MEDICAL ARTS PHARMACY
Entity Type:Organization
Organization Name:MEDICAL ARTS PHARMACY
Other - Org Name:MEDICAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:PITALO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-432-7071
Mailing Address - Street 1:120 CAILLAVET ST
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530-4102
Mailing Address - Country:US
Mailing Address - Phone:228-432-7071
Mailing Address - Fax:228-432-7910
Practice Address - Street 1:120 CAILLAVET ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-4102
Practice Address - Country:US
Practice Address - Phone:228-432-7071
Practice Address - Fax:228-432-7910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS004240113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2050617OtherPK
MS0033103Medicaid