MEDICARE: GENTEX PHARMA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site	06677/6.1	MS

General Provider Information

NPI Number	:	1114373586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENTEX PHARMA

Provider Business Mailing Address
First Line	:	121 MARKETRIDGE DR
Second Line	:	SUITE C
City	:	RIDGELAND
State	:	MS
Zip	:	39157-6027
Country	:	US
Telephone Number	:	601-990-9497
Fax Number	:	601-510-9318

Provider Business Practice Location Address
First Line	:	121 MARKETRIDGE DR
Second Line	:	SUITE C
City	:	RIDGELAND
State	:	MS
Zip	:	39157-6027
Country	:	US
Telephone Number	:	601-990-9497
Fax Number	:	601-510-9318

Authorized Official
Title or Position	:	OWNER
Name	:	FORD JENNINGS MUNDY
Credential	:	PERSON IN CHARGE
Telephone Number	:	870-243-1687

Provider Enumeration Date	:	05/04/2016
Last Update Date	:	05/04/2016

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