Healthcare Provider Details

I. General information

NPI: 1225220437
Provider Name (Legal Business Name): MAGNOLIA MEDICAL SUPPLIES AND EQUIPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2007
Last Update Date: 08/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W MAIN ST
SENATOBIA MS
38668-2146
US

IV. Provider business mailing address

PO BOX 85
TUNICA MS
38676-0085
US

V. Phone/Fax

Practice location:
  • Phone: 662-301-1013
  • Fax: 662-301-1015
Mailing address:
  • Phone: 662-301-1013
  • Fax: 662-357-7621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHNNY MACK HARDY
Title or Position: CEO
Credential:
Phone: 662-301-1013