Healthcare Provider Details

I. General information

NPI: 1003655903
Provider Name (Legal Business Name): TRISTATE INFUSION CLINICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9140 HIGHWAY 51 N STE C
SOUTHAVEN MS
38671-1233
US

IV. Provider business mailing address

9140 HIGHWAY 51 N STE C
SOUTHAVEN MS
38671-1233
US

V. Phone/Fax

Practice location:
  • Phone: 662-260-3366
  • Fax: 662-269-1568
Mailing address:
  • Phone: 662-260-3366
  • Fax: 662-269-1568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICK RYAN MCFERRIN
Title or Position: OWNER
Credential:
Phone: 662-260-3366