# WAVELAND PHARMACY LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** WAVELAND PHARMACY
- **Organization subpart:** No

## Provider details

- **NPI number:** 1679507644
- **Authorized official:** RUDY LETELLIER RPH (OWNER PHCST)
- **Authorized official phone:** (228) 463-1055

## Contact information

- **Practice address:** 112 AUDERER BLVD, WAVELAND, MS 39576-2432
- **Practice address phone:** (228) 463-1055
- **Practice address fax:** (228) 463-0117
- **Mailing address:** PO BOX 4617, BAY ST LOUIS, MS 39521-4617
- **Mailing address phone:** (228) 463-1055

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336C0003X | Community/Retail Pharmacy | F05352 | MS | Yes |

## Other

- **Enumeration date:** 07/10/2006
- **Last updated:** 12/14/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 00330669 | — | MS |
| 01 | — | 2046344 | PK | — |