Provider Demographics
NPI:1952471492
Name:WELLS LOTT VILLAGE PHARMACY
Entity Type:Organization
Organization Name:WELLS LOTT VILLAGE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LOWELL
Authorized Official - Middle Name:G
Authorized Official - Last Name:LOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:622-335-1173
Mailing Address - Street 1:1442 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-7026
Mailing Address - Country:US
Mailing Address - Phone:662-335-1173
Mailing Address - Fax:662-335-0731
Practice Address - Street 1:1442 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7026
Practice Address - Country:US
Practice Address - Phone:662-335-1173
Practice Address - Fax:662-335-0731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0156001.1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0034860Medicaid
MS0034860Medicaid