Provider Demographics
NPI:1366803512
Name:PHARMACY INNOVATIONS LLC
Entity type:Organization
Organization Name:PHARMACY INNOVATIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-612-1385
Mailing Address - Street 1:715 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6339
Mailing Address - Country:US
Mailing Address - Phone:855-612-1385
Mailing Address - Fax:855-612-1386
Practice Address - Street 1:715 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6339
Practice Address - Country:US
Practice Address - Phone:855-612-1385
Practice Address - Fax:855-612-1386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MS14763333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159492OtherPK
MS01381865Medicaid