Healthcare Provider Details

I. General information

NPI: 1255677001
Provider Name (Legal Business Name): MIDSOUTH MEDICAL SPECIALTIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 HIGHWAY 515 SOUTH
HERNANDO MS
38632
US

IV. Provider business mailing address

2260 HIGHWAY 515 SOUTH
HERNANDO MS
38632
US

V. Phone/Fax

Practice location:
  • Phone: 662-449-9075
  • Fax: 662-449-3414
Mailing address:
  • Phone: 662-449-9075
  • Fax: 662-449-3414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number11889
License Number StateMS

VIII. Authorized Official

Name: MR. EDDIE O'BANNON
Title or Position: OWNER
Credential:
Phone: 662-449-9075