Diamondhead Health Mart Pharmacy,LLC
Organization Active NPI Community/Retail Pharmacy · Diamondhead, MS
NPI 1003207895 · NPPES record last updated Nov 30, 2021
Key facts
- NPI
- 1003207895
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 14221/1.1 (MS)
- Legal business name
- DIAMONDHEAD HEALTH MART PHARMACY,LLC
- Practice address
- 4405 E Aloha Dr # Aa
Diamondhead, MS 39525-3380 - Phone
- (228) 222-4662
- Fax
- (228) 222-4733
- NPI assigned
- Feb 15, 2015
- Organization subpart
- No
Authorized official
- Name
- Mr. Rudy Allen Letellier, RPH
- Title
- Owner/Pharmacist
- Phone
- (228) 222-4662
Practitioners 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20210629001683 | MS | Part B Supplier - Mass Immunization (Roster Biller Only) | 7113328048 | Practice locations: Diamondhead, MS |
National Provider Directory
Locations
4405 E Aloha Dr
Diamondhead, MS 39525
Phone (228) 222-4662
4349A Gex Rd
Diamondhead, MS 39525
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Retail Pharmacy | 3336C0003X | 14221/1.1 | MS | Yes |
Addresses
Primary practice location
4405 E Aloha Dr # Aa
Diamondhead, MS 39525-3380
Mailing address
PO Box 4258
Bay St Louis, MS 39521-4258
Phone (228) 222-4662
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 08129049 | Medicaid | MS |
Other names
- Diamondhead Health Mart Pharmacy
- Pharmacy in Diamondhead
Other providers in Diamondhead, MS
- D and F Inc
- Thanh Dang
- David F. Roberts, MD
- Abigail Dearman
- Erin Adam Dewitt
- Diamondhead Medicine, LLC
- Diamondhead Pharmacy & Gifts, Inc
- Diamondhead Urgent Care
- Tracy Rene Diercks
- Duncan F Matheson III DDS PA
All providers in Diamondhead, MS · Community/Retail Pharmacy in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 30, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.