Organization
HATTIESBURG CLINIC PA
Active
Other names
OWL DRUG STORE
Organization subpart
No
Provider details
NPI number
Authorized official
DIANE ASHLEY RPH (PHCY DIR)
(601) 268-2740
Entity
Organization
Contact information
Practice address
MEDICAL BLVD, STE 2, HATTIESBURG, MS 39401
(601) 268-5740
(601) 268-5858
Mailing address
MEDICAL BLVD, STE 2, HATTIESBURG, MS 39401
(601) 268-5740
(601) 268-5858
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
01821/1.1
MS
3336L0003X
Long Term Care Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00030291
—
MS
01
—
2045095
PK
—
Enumeration date
07/30/2006
Last updated
02/21/2017
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