Provider Demographics
NPI:1851390892
Name:COVENANT PHARMACY LLC
Entity Type:Organization
Organization Name:COVENANT PHARMACY LLC
Other - Org Name:COVENANT PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WHITWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:601-326-5760
Mailing Address - Street 1:371A HIGHLAND COLONY PKWY
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-6035
Mailing Address - Country:US
Mailing Address - Phone:601-326-5760
Mailing Address - Fax:601-326-5770
Practice Address - Street 1:371A HIGHLAND COLONY PKWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-6035
Practice Address - Country:US
Practice Address - Phone:601-326-5760
Practice Address - Fax:601-326-5770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS050873336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330627Medicaid
2046319OtherPK