Provider Demographics
NPI:1821190463
Name:MKB PHARMACY, INC
Entity Type:Organization
Organization Name:MKB PHARMACY, INC
Other - Org Name:TD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:PISARICH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:228-832-1414
Mailing Address - Street 1:12372 HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2741
Mailing Address - Country:US
Mailing Address - Phone:228-832-1414
Mailing Address - Fax:228-832-1479
Practice Address - Street 1:12372 HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2741
Practice Address - Country:US
Practice Address - Phone:228-832-1414
Practice Address - Fax:228-832-1479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS02829/01.13336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330221Medicaid
MS2508577OtherNCPDP/NABP NUMBER
MS18124OtherBOARD OF PHARMACY PERMIT
MS18124OtherBOARD OF PHARMACY PERMIT