Provider Demographics
NPI:1689601957
Name:PICAYUNE DRUG CO., INC.
Entity type:Organization
Organization Name:PICAYUNE DRUG CO., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:L
Authorized Official - Last Name:FAILLA
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:601-798-4846
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-0010
Mailing Address - Country:US
Mailing Address - Phone:601-798-4846
Mailing Address - Fax:601-798-4825
Practice Address - Street 1:110 HIGHWAY 11 N
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3312
Practice Address - Country:US
Practice Address - Phone:601-798-4846
Practice Address - Fax:601-798-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS055-05477-9332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00045164Medicaid
0236780001Medicare ID - Type Unspecified
MS00045164Medicaid