Provider Demographics
NPI:1124679873
Name:FAMILY DRUG MART OF SUMRALL, LLC
Entity type:Organization
Organization Name:FAMILY DRUG MART OF SUMRALL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:YANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:504-338-7992
Mailing Address - Street 1:2299 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5605
Mailing Address - Country:US
Mailing Address - Phone:504-338-7992
Mailing Address - Fax:985-265-4550
Practice Address - Street 1:4233 ROCKY BRANCH RD STE B
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-4142
Practice Address - Country:US
Practice Address - Phone:504-338-7992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-24
Last Update Date:2021-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3303247Medicaid