Healthcare Provider Details

I. General information

NPI: 1740287028
Provider Name (Legal Business Name): SOUTHERN PULMONARY CARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316A COFFEE ST
PONTOTOC MS
38863-2606
US

IV. Provider business mailing address

PO BOX 41
PONTOTOC MS
38863-0041
US

V. Phone/Fax

Practice location:
  • Phone: 662-489-3116
  • Fax: 662-489-3388
Mailing address:
  • Phone: 662-489-3116
  • Fax: 662-489-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number02615/11.1
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number04138102.5
License Number StateMS

VIII. Authorized Official

Name: MR. CARL WAYNE MAHON
Title or Position: OWNER
Credential: CRT
Phone: 662-489-3116