1568012383 NPI number — MOORE'S PHARMACY LENA LLC

Table of content: (NPI 1568012383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568012383 NPI number — MOORE'S PHARMACY LENA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOORE'S PHARMACY LENA 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:
Provider Other Organization Name Type Code:
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:
1568012383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 80
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39094-0080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-780-2757
Provider Business Mailing Address Fax Number:
601-724-9438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 GRAND AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-780-2757
Provider Business Practice Location Address Fax Number:
601-724-9438
Provider Enumeration Date:
09/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
BRETT
Authorized Official Middle Name:
CHAPIN
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
601-706-5417

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06620077 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com