Healthcare Provider Details

I. General information

NPI: 1356718233
Provider Name (Legal Business Name): HORN LAKE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 GOODMAN RD W
HORN LAKE MS
38637-1172
US

IV. Provider business mailing address

1019 GOVERNMENT ST SUITE F
OCEAN SPRINGS MS
39564-3860
US

V. Phone/Fax

Practice location:
  • Phone: 662-342-6677
  • Fax: 662-342-0203
Mailing address:
  • Phone: 228-447-3823
  • Fax: 228-447-3812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number14467
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SHEETAL SHARMA
Title or Position: MEMBER
Credential:
Phone: 662-342-6677