=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841395191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POTOTOC HEALTH SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 01/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 176 S MAIN ST
-----------------------------------------------------
City | PONTOTOC
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38863-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-488-7629
-----------------------------------------------------
Fax | 662-488-7714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 176 S MAIN ST
-----------------------------------------------------
City | PONTOTOC
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38863-3311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-488-7629
-----------------------------------------------------
Fax | 662-488-7714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE SECRETARY
-----------------------------------------------------
Name | BRUCE TOPPIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-377-4229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336I0012X
-----------------------------------------------------
Taxonomy Name | Institutional Pharmacy
-----------------------------------------------------
License Number | 00902/3.1
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------