1376620898 NPI number — CONTROLEX ENTERPRISES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376620898 NPI number — CONTROLEX ENTERPRISES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONTROLEX ENTERPRISES, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1376620898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 INGALLS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASCAGOULA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39567-5650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-769-7067
Provider Business Mailing Address Fax Number:
228-762-1756

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11936 HIGHWAY 57
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCLEAVE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39565-8298
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-826-4403
Provider Business Practice Location Address Fax Number:
228-826-5165
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANNON
Authorized Official First Name:
MODENA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PHARMACY OPERATIONS MANAGER
Authorized Official Telephone Number:
228-769-7067

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  01145/01.2 , 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: 00330424 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2510560 . This is a "NCPDP" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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