Healthcare Provider Details

I. General information

NPI: 1629091616
Provider Name (Legal Business Name): SOUTH MISSISSIPPI REGIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 W RAILROAD ST
LONG BEACH MS
39560-4106
US

IV. Provider business mailing address

1170 W RAILROAD ST
LONG BEACH MS
39560-4106
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-1331
  • Fax: 228-867-1459
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number01345041
License Number StateMS

VIII. Authorized Official

Name: LIONEL HEIDINGSFELDER
Title or Position: PHARMACIST
Credential: RPH
Phone: 228-867-1331