Provider Demographics
NPI:1356179295
Name:MAGNOLIA MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:MAGNOLIA MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUMPERS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:601-441-4400
Mailing Address - Street 1:79 HIGHPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-9536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:431 BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-3056
Practice Address - Country:US
Practice Address - Phone:601-736-8212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center