Healthcare Provider Details

I. General information

NPI: 1295220598
Provider Name (Legal Business Name): MS STATE VETERANS HOME KOSCIUSKO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 AUTUMN RIDGE DR
KOSCIUSKO MS
39090-3242
US

IV. Provider business mailing address

310 AUTUMN RIDGE DR
KOSCIUSKO MS
39090-3242
US

V. Phone/Fax

Practice location:
  • Phone: 662-290-3000
  • Fax: 662-289-7824
Mailing address:
  • Phone: 662-290-3000
  • Fax: 662-289-7824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number806
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID POCHE
Title or Position: PHARMACIST
Credential:
Phone: 662-290-3000