Provider Demographics
NPI:1922544865
Name:DVC PHARMACY LLC
Entity Type:Organization
Organization Name:DVC PHARMACY LLC
Other - Org Name:DVC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-513-6600
Mailing Address - Street 1:PO BOX 511
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-0511
Mailing Address - Country:US
Mailing Address - Phone:662-257-2357
Mailing Address - Fax:662-257-2399
Practice Address - Street 1:1107 EARL FRYE BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5519
Practice Address - Country:US
Practice Address - Phone:662-257-2357
Practice Address - Fax:662-257-2399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS151003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167168OtherPK