Provider Demographics
NPI:1972685097
Name:CONTROLEX ENTRPRISES, INC
Entity Type:Organization
Organization Name:CONTROLEX ENTRPRISES, INC
Other - Org Name:GULF COAST SAV-REX #631
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MODENA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-769-7067
Mailing Address - Street 1:PO BOX 2070
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39569-2070
Mailing Address - Country:US
Mailing Address - Phone:228-762-4622
Mailing Address - Fax:228-762-1756
Practice Address - Street 1:1420 INGALLS AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-5650
Practice Address - Country:US
Practice Address - Phone:228-762-4622
Practice Address - Fax:228-762-1756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01128/01.23336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0032191Medicaid
MS2506369OtherNCPDP
MS0032191Medicaid