=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568132058
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTAL CARE SPECIALTY PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2021
-----------------------------------------------------
Last Update Date | 09/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4079 PEMBERTON SQUARE BLVD
-----------------------------------------------------
City | VICKSBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39180-5580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-618-0002
-----------------------------------------------------
Fax | 601-501-7831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 820474
-----------------------------------------------------
City | VICKSBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39182-0474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-618-0002
-----------------------------------------------------
Fax | 601-501-7831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. DE'SHAWN NICHELLE GRAVES
-----------------------------------------------------
Credential | CPHT
-----------------------------------------------------
Telephone | 601-618-0002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------