Healthcare Provider Details

I. General information

NPI: 1932864667
Provider Name (Legal Business Name): MIDSOUTH MEDICAL SPECIALTIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1433 GOODMAN RD W
HORN LAKE MS
38637-1404
US

IV. Provider business mailing address

1433 GOODMAN RD W
HORN LAKE MS
38637-1404
US

V. Phone/Fax

Practice location:
  • Phone: 901-674-3148
  • Fax:
Mailing address:
  • Phone: 662-280-7455
  • Fax:

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

VIII. Authorized Official

Name: JAKE O'BANNON
Title or Position: PHARMACIST
Credential:
Phone: 662-280-7455