Healthcare Provider Details

I. General information

NPI: 1538597554
Provider Name (Legal Business Name): NEWSOUTH NEUROSPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 FLOWOOD DR
FLOWOOD MS
39232-9019
US

IV. Provider business mailing address

2470 FLOWOOD DR
FLOWOOD MS
39232-9019
US

V. Phone/Fax

Practice location:
  • Phone: 601-983-2840
  • Fax: 601-983-2845
Mailing address:
  • Phone: 601-420-1950
  • Fax: 601-420-1951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1270111
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA HANSEN
Title or Position: PHARMACIST IN CHARGE
Credential: PHARMD
Phone: 601-420-1950