Healthcare Provider Details

I. General information

NPI: 1487972568
Provider Name (Legal Business Name): THE CLINIC AT FARMERS MEDSHOPPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 HIGHWAY 587
FOXWORTH MS
39483
US

IV. Provider business mailing address

P.O. BOX 669
FOXWORTH MS
39483
US

V. Phone/Fax

Practice location:
  • Phone: 601-424-3540
  • Fax: 601-424-3544
Mailing address:
  • Phone: 601-424-3540
  • Fax: 601-424-3544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: MR. CLAYTON A. FARMER
Title or Position: OWNER
Credential:
Phone: 601-424-3540