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General NPI Number Information
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NPI Number | 1932864667
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Entity Type | Organization
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Legal Business Name | MIDSOUTH MEDICAL SPECIALTIES LLC
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Dates
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Enumeration Date | 11/08/2021
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Last Update Date | 11/08/2021
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Provider Practice Location Address
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Address Line | 1433 GOODMAN RD W
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City | HORN LAKE
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State | MS
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Zip | 38637-1404
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Country | US
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Telephone | 901-674-3148
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Fax |
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Provider Business Mailing Address
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Address Line | 1433 GOODMAN RD W
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City | HORN LAKE
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State | MS
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Zip | 38637-1404
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Country | US
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Telephone | 662-280-7455
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Fax |
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Authorized Official
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Title or Position | PHARMACIST
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Name | JAKE O'BANNON
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Credential |
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Telephone | 662-280-7455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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