Provider Demographics
NPI:1023549060
Name:BRENTWOOD ACQUISITION PHARMACY
Entity Type:Organization
Organization Name:BRENTWOOD ACQUISITION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:601-936-7845
Mailing Address - Street 1:3531 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8049
Mailing Address - Country:US
Mailing Address - Phone:601-936-7845
Mailing Address - Fax:601-936-7846
Practice Address - Street 1:3531 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8049
Practice Address - Country:US
Practice Address - Phone:601-936-7845
Practice Address - Fax:601-936-7846
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRENTWOOD ACQUISITION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-22
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05066/3.13336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy