# FREDS WESTSIDE PHARMACY INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1265520290
- **Authorized official:** ROGER G CRUSE (OWNER)
- **Authorized official phone:** (601) 798-8888

## Contact information

- **Practice address:** 207 KIRKWOOD ST, PICAYUNE, MS 39466-3835
- **Practice address phone:** (601) 798-8888
- **Practice address fax:** (601) 799-1012
- **Mailing address:** 207 KIRKWOOD ST, PICAYUNE, MS 39466-3835
- **Mailing address phone:** (601) 798-8888
- **Mailing address fax:** (601) 799-1012

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 3336C0003X | Community/Retail Pharmacy | — | NULL | Yes |

## Other

- **Enumeration date:** 10/11/2006
- **Last updated:** 08/05/2019

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 01786239 | MEDICAID DMERC | MS |
| 05 | — | 0330105 | — | MS |