Organization
WAVELAND PHARMACY LLC
Active
Other names
WAVELAND PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
RUDY LETELLIER RPH (OWNER PHCST)
(228) 463-1055
Entity
Organization
Contact information
Practice address
112 AUDERER BLVD, WAVELAND, MS 39576-2432
(228) 463-1055
(228) 463-0117
Mailing address
PO BOX 4617, BAY ST LOUIS, MS 39521-4617
(228) 463-1055
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
F05352
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00330669
—
MS
01
—
2046344
PK
—
Enumeration date
07/10/2006
Last updated
12/14/2015
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