Provider Demographics
NPI:1336192939
Name:APS PHARMACY 801 LLC
Entity Type:Organization
Organization Name:APS PHARMACY 801 LLC
Other - Org Name:APS PHARMACY #801, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-536-0384
Mailing Address - Street 1:480 AIRPORT INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5870
Mailing Address - Country:US
Mailing Address - Phone:662-536-0384
Mailing Address - Fax:662-536-4207
Practice Address - Street 1:480 AIRPORT INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5870
Practice Address - Country:US
Practice Address - Phone:662-536-0384
Practice Address - Fax:662-536-4207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336S0011X
MS05956263336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05908836Medicaid
2120958OtherPK