Organization
FREDS WESTSIDE PHARMACY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ROGER G CRUSE (OWNER)
(601) 798-8888
Entity
Organization
Contact information
Practice address
207 KIRKWOOD ST, PICAYUNE, MS 39466-3835
(601) 798-8888
(601) 799-1012
Mailing address
207 KIRKWOOD ST, PICAYUNE, MS 39466-3835
(601) 798-8888
(601) 799-1012
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01786239
MEDICAID DMERC
MS
05
—
0330105
—
MS
Enumeration date
10/11/2006
Last updated
08/05/2019
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