Provider Demographics
NPI:1922027622
Name:PICAYUNE DRUG CO., INC.
Entity Type:Organization
Organization Name:PICAYUNE DRUG CO., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAILLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-798-4846
Mailing Address - Street 1:110 HIGHWAY 11 N
Mailing Address - Street 2:P.O. BOX 10
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3312
Mailing Address - Country:US
Mailing Address - Phone:601-798-4846
Mailing Address - Fax:601-798-4825
Practice Address - Street 1:110 HIGHWAY 11 N
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3312
Practice Address - Country:US
Practice Address - Phone:601-798-4846
Practice Address - Fax:601-798-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00937/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2506600OtherNABP
MS00030106Medicaid
MS00045164Medicaid
0236780001Medicare NSC