Provider Demographics
NPI:1487806121
Name:MIDSOUTH MEDICAL SPECIALTIES LLC
Entity type:Organization
Organization Name:MIDSOUTH MEDICAL SPECIALTIES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUPER
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUGS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-280-7455
Mailing Address - Street 1:PO BOX 563
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-0563
Mailing Address - Country:US
Mailing Address - Phone:662-280-7455
Mailing Address - Fax:662-280-7457
Practice Address - Street 1:1433 GOODMAN RD W
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637
Practice Address - Country:US
Practice Address - Phone:662-280-7455
Practice Address - Fax:662-280-7457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336S0011X, 3336C0003X, 3336C0004X, 3336H0001X, 3336L0003X
MS251F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251F00000XAgenciesHome Infusion
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02434788Medicaid
TN1534074Medicaid
2117404OtherPK