Provider Demographics
NPI:1770660201
Name:CONTROLEX ENTERPRISES, INC.
Entity Type:Organization
Organization Name:CONTROLEX ENTERPRISES, INC.
Other - Org Name:LOVELACE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MODENA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-769-7067
Mailing Address - Street 1:1420 INGALLS AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-5650
Mailing Address - Country:US
Mailing Address - Phone:228-875-4272
Mailing Address - Fax:228-875-2651
Practice Address - Street 1:801 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4637
Practice Address - Country:US
Practice Address - Phone:228-875-4272
Practice Address - Fax:228-875-2651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07128/01.2333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00036331Medicaid
MS2586709OtherNCPDP
MS00036331Medicaid