Healthcare Provider Details

I. General information

NPI: 1972925303
Provider Name (Legal Business Name): RELIANT MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3532 MANOR DR STE 4
VICKSBURG MS
39180-5629
US

IV. Provider business mailing address

PO BOX 2293
MONROE LA
71207-2293
US

V. Phone/Fax

Practice location:
  • Phone: 877-354-2688
  • Fax: 318-322-0998
Mailing address:
  • Phone: 877-354-2688
  • Fax: 318-354-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number12953/ 2.6
License Number StateMS

VIII. Authorized Official

Name: BRAD SMITH
Title or Position: CEO
Credential:
Phone: 318-322-8326