Healthcare Provider Details

I. General information

NPI: 1538522446
Provider Name (Legal Business Name): KINETIX GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 BUSINESS PARK DR STE H SUITE H
RIDGELAND MS
39157-6017
US

IV. Provider business mailing address

104 BUSINESS PARK DR SUITE H
RIDGELAND MS
39157-6017
US

V. Phone/Fax

Practice location:
  • Phone: 662-803-2094
  • Fax: 601-326-7377
Mailing address:
  • Phone: 662-803-2094
  • Fax: 601-326-7377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number14764/1.1
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER SARTAIN
Title or Position: LICENSING SPECIALIST
Credential:
Phone: 601-983-1239