Healthcare Provider Details

I. General information

NPI: 1659076107
Provider Name (Legal Business Name): INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 AIRPORT ROAD
FOREST MS
39074
US

IV. Provider business mailing address

PO BOX D
FOREST MS
39074-0558
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4151
  • Fax:
Mailing address:
  • Phone: 601-469-4151
  • Fax: 601-469-9927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN P LEE
Title or Position: COB
Credential: MD
Phone: 601-469-4151