Provider Demographics
NPI:1932227089
Name:PIONEER FAMILY PHARMACY
Entity Type:Organization
Organization Name:PIONEER FAMILY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST NI CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:FORTENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-937-1672
Mailing Address - Street 1:502 JACKSON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-3300
Mailing Address - Country:US
Mailing Address - Phone:662-369-4249
Mailing Address - Fax:662-304-4018
Practice Address - Street 1:502 JACKSON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-3300
Practice Address - Country:US
Practice Address - Phone:662-369-4249
Practice Address - Fax:662-304-4018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS067483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2586317OtherNABP
MI06229094Medicaid
MIBP9469164OtherDEA
MI5541770002Medicare ID - Type Unspecified