Provider Demographics
NPI:1104985100
Name:PATTERSONS PHARMACY CO INC
Entity type:Organization
Organization Name:PATTERSONS PHARMACY CO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES AND PHARM
Authorized Official - Prefix:
Authorized Official - First Name:BURT
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:228-875-0158
Mailing Address - Street 1:1121 OCEAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3421
Mailing Address - Country:US
Mailing Address - Phone:228-875-0158
Mailing Address - Fax:228-875-2266
Practice Address - Street 1:1121 OCEAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3421
Practice Address - Country:US
Practice Address - Phone:228-875-0158
Practice Address - Fax:228-875-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS011253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0093556Medicaid
2508565OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MS0093556Medicaid