Healthcare Provider Details

I. General information

NPI: 1487806121
Provider Name (Legal Business Name): MIDSOUTH MEDICAL SPECIALTIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 01/08/2024
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 GOODMAN RD W
HORN LAKE MS
38637
US

IV. Provider business mailing address

PO BOX 563
HERNANDO MS
38632-0563
US

V. Phone/Fax

Practice location:
  • Phone: 662-280-7455
  • Fax: 662-280-7457
Mailing address:
  • Phone: 662-280-7455
  • Fax: 662-280-7457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SUPER DRUGS
Title or Position: OWNER
Credential: RPH
Phone: 662-280-7455