Healthcare Provider Details

I. General information

NPI: 1689039711
Provider Name (Legal Business Name): RIVER REGION HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 HIGHWAY 61 N PHARMACY
VICKSBURG MS
39183-8211
US

IV. Provider business mailing address

118 BRECKENRIDGE DR APT 205
HATTIESBURG MS
39402-3504
US

V. Phone/Fax

Practice location:
  • Phone: 601-415-3809
  • Fax:
Mailing address:
  • Phone: 601-415-3809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberE-13632
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberE-13632
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberE-13632
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberE-13632
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License NumberE-13632
License Number StateMS

VIII. Authorized Official

Name: V KAREN FLINN
Title or Position: VP
Credential:
Phone: 361-579-0315