Provider Demographics
NPI:1043304033
Name:MEDI MART PHARMACIES OF MISSISSIPPI, INC.
Entity Type:Organization
Organization Name:MEDI MART PHARMACIES OF MISSISSIPPI, INC.
Other - Org Name:MEDI MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DUBOSE
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:228-474-1011
Mailing Address - Street 1:3737 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-5107
Mailing Address - Country:US
Mailing Address - Phone:228-474-1011
Mailing Address - Fax:228-474-1033
Practice Address - Street 1:3737 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-5107
Practice Address - Country:US
Practice Address - Phone:228-474-1011
Practice Address - Fax:228-474-1033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01148/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030113Medicaid
1111110001Medicare NSC