Provider Demographics
NPI:1073524583
Name:EMMANUEL RIDGE COMM PHCY
Entity Type:Organization
Organization Name:EMMANUEL RIDGE COMM PHCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:EZEM
Authorized Official - Suffix:
Authorized Official - Credentials:RN CM CLNC
Authorized Official - Phone:601-927-9839
Mailing Address - Street 1:PO BOX 1522
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-1522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2073 HIGHWAY 49 S
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-9422
Practice Address - Country:US
Practice Address - Phone:601-845-3544
Practice Address - Fax:601-845-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS069390113336C0003X
3336I0012X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336I0012XSuppliersPharmacyInstitutional Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2586622OtherOTHER ID NUMBER-COMMERCIAL NUMBER