=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760400188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVERSIFIED INFUSIONCARE SOLUTIONS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 823 HIGHWAY 12 W SUITE E
-----------------------------------------------------
City | STARKVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39759-3593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-320-9696
-----------------------------------------------------
Fax | 662-320-9616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5047
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39302-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-447-4095
-----------------------------------------------------
Fax | 601-482-7490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STAN HAMILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-320-9696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 04633/02.1
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------