# NORTHEAST MENTAL HEALTH-MENTAL RETARDATION COMMISSION

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Lifecore Pharmacy Tupelo
- **Organization subpart:** No

## Provider details

- **NPI number:** 1427489517
- **Authorized official:** VAN WATSON BS PHARMACY (DIRECTOR OF PHARMACY)
- **Authorized official phone:** (662) 912-5006

## Contact information

- **Practice address:** 499 GLOSTER CREEK VLG STE A3, TUPELO, MS 38801-4600
- **Practice address phone:** (662) 912-5006
- **Practice address fax:** (662) 680-5125
- **Mailing address:** 499 GLOSTER CREEK VLG STE A3, TUPELO, MS 38801-4600
- **Mailing address phone:** (662) 912-5006
- **Mailing address fax:** (662) 680-5125

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | 12959/5.1 | MS | Yes |

## Other

- **Enumeration date:** 11/27/2013
- **Last updated:** 04/19/2017

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 07371351 | — | MS |
| 01 | — | 2143598 | PK | — |