Healthcare Provider Details

I. General information

NPI: 1962999789
Provider Name (Legal Business Name): STATE VETERANS AFFAIRS BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 LINDBERGH DR
JACKSON MS
39209-3855
US

IV. Provider business mailing address

4607 LINDBERGH DR
JACKSON MS
39209-3855
US

V. Phone/Fax

Practice location:
  • Phone: 601-353-6142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: VELEKA GRADY
Title or Position: PHARMACIST
Credential: PHARM.D
Phone: 601-353-6142