Organization
NORTHEAST MENTAL HEALTH-MENTAL RETARDATION COMMISSION
Active
Other names
Lifecore Pharmacy Tupelo
Organization subpart
No
Provider details
NPI number
Authorized official
VAN WATSON BS PHARMACY (DIRECTOR OF PHARMACY)
(662) 912-5006
Entity
Organization
Contact information
Practice address
499 GLOSTER CREEK VLG STE A3, TUPELO, MS 38801-4600
(662) 912-5006
(662) 680-5125
Mailing address
499 GLOSTER CREEK VLG STE A3, TUPELO, MS 38801-4600
(662) 912-5006
(662) 680-5125
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
12959/5.1
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07371351
—
MS
01
—
2143598
PK
—
Enumeration date
11/27/2013
Last updated
04/19/2017
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