=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063525558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACH CREEK PLANTING CO.,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 498 W BANKHEAD ST
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38652-3319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-534-4774
-----------------------------------------------------
Fax | 662-534-4775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 867
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38652-0867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-534-4774
-----------------------------------------------------
Fax | 662-534-4775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PURCHASING AGENT
-----------------------------------------------------
Name | MR. JOHN KELLY THOMAS III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-534-4774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BX2000X
-----------------------------------------------------
Taxonomy Name | Oxygen Equipment & Supplies (DME)
-----------------------------------------------------
License Number | 04919/11.1
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------