Provider Demographics
NPI:1760537393
Name:BRISTER BROTHERS, INC
Entity Type:Organization
Organization Name:BRISTER BROTHERS, INC
Other - Org Name:H & W COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVOTIE
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:BRISTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-226-1212
Mailing Address - Street 1:1117 SUNSET DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4080
Mailing Address - Country:US
Mailing Address - Phone:662-226-1212
Mailing Address - Fax:662-229-0260
Practice Address - Street 1:1117 SUNSET DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4080
Practice Address - Country:US
Practice Address - Phone:662-226-1212
Practice Address - Fax:662-229-0260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03999333600000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440562Medicaid
MS00330315Medicaid
MS1240470001Medicare ID - Type Unspecified