Provider Demographics
NPI:1063710820
Name:SALTILLO PHARMACY SERVICES LLC
Entity type:Organization
Organization Name:SALTILLO PHARMACY SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST, OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:662-279-0599
Mailing Address - Street 1:138 COURTLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866
Mailing Address - Country:US
Mailing Address - Phone:662-279-0599
Mailing Address - Fax:662-269-2037
Practice Address - Street 1:2698 HIGHWAY 145
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-6941
Practice Address - Country:US
Practice Address - Phone:662-269-2781
Practice Address - Fax:662-269-2037
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALTILLO PHARMACY SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-03
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09835570Medicaid