Healthcare Provider Details

I. General information

NPI: 1215349667
Provider Name (Legal Business Name): MIDSOUTH MEDICAL SPECIALTIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 CENTRAL AVENUE
HOT SPRINGS AR
71913
US

IV. Provider business mailing address

PO BOX 563
HERNANDO MS
38632-0563
US

V. Phone/Fax

Practice location:
  • Phone: 14-639-9225
  • Fax: 501-463-9925
Mailing address:
  • Phone: 501-463-9922
  • Fax: 501-463-9925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: EDDIE O'BANNON
Title or Position: OWNER
Credential:
Phone: 901-262-4317