Provider Demographics
NPI:1336416973
Name:DOWNTOWN PHARMACY
Entity Type:Organization
Organization Name:DOWNTOWN PHARMACY
Other - Org Name:DOWNTOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-544-7111
Mailing Address - Street 1:511 W LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3504
Mailing Address - Country:US
Mailing Address - Phone:601-544-7111
Mailing Address - Fax:601-544-7154
Practice Address - Street 1:511 W LAUREL AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3504
Practice Address - Country:US
Practice Address - Phone:601-544-7111
Practice Address - Fax:601-544-7154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS09182/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05232866Medicaid
2132768OtherPK