Provider Demographics
NPI:1992292536
Name:MANTACHIE PHARMACY LLC
Entity type:Organization
Organization Name:MANTACHIE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KATLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPRADLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-282-7000
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855-0096
Mailing Address - Country:US
Mailing Address - Phone:662-322-3901
Mailing Address - Fax:
Practice Address - Street 1:3309 HIGHWAY 371 N
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855
Practice Address - Country:US
Practice Address - Phone:662-322-3901
Practice Address - Fax:662-640-4116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MS17079/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2177084OtherPK