Provider Demographics
NPI:1003207895
Name:DIAMONDHEAD HEALTH MART PHARMACY,LLC
Entity type:Organization
Organization Name:DIAMONDHEAD HEALTH MART PHARMACY,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LETELLIER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:228-222-4662
Mailing Address - Street 1:PO BOX 4258
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39521-4258
Mailing Address - Country:US
Mailing Address - Phone:228-222-4662
Mailing Address - Fax:228-222-4733
Practice Address - Street 1:4405 E ALOHA DR # AA
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3380
Practice Address - Country:US
Practice Address - Phone:228-222-4662
Practice Address - Fax:228-222-4733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-15
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14221/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08129049Medicaid