Provider Demographics
NPI:1265148209
Name:MARKETPLACE PHARMACY GROUP LLC
Entity type:Organization
Organization Name:MARKETPLACE PHARMACY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LINDSEY
Authorized Official - Last Name:VIVIEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:601-436-7969
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-1005
Mailing Address - Country:US
Mailing Address - Phone:601-794-8634
Mailing Address - Fax:
Practice Address - Street 1:157 SHELBY SPEIGHTS DR
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-4094
Practice Address - Country:US
Practice Address - Phone:601-794-8634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy