Provider Demographics
NPI:1356718233
Name:HORN LAKE FAMILY PRACTICE
Entity type:Organization
Organization Name:HORN LAKE FAMILY PRACTICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHEETAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-342-6677
Mailing Address - Street 1:1019 GOVERNMENT ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3860
Mailing Address - Country:US
Mailing Address - Phone:228-447-3823
Mailing Address - Fax:228-447-3812
Practice Address - Street 1:3102 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1172
Practice Address - Country:US
Practice Address - Phone:662-342-6677
Practice Address - Fax:662-342-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
MS144673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2153358OtherPK