1356406490 NPI number — D AND L MED LLC

Table of content: (NPI 1356406490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356406490 NPI number — D AND L MED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
D AND L MED LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OLE RIVER PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356406490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9830
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84109-9830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-540-4748
Provider Business Mailing Address Fax Number:
801-716-4872

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5315 OLD HIGHWAY 11
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
HATTIESBURG
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39402-6224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-271-2006
Provider Business Practice Location Address Fax Number:
800-716-4177
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MYERS
Authorized Official First Name:
DANNY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-408-6250

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  07214/2.3 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03001314 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2047458 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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