Provider Demographics
NPI:1073849626
Name:SSD LLC
Entity Type:Organization
Organization Name:SSD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-534-4774
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-0867
Mailing Address - Country:US
Mailing Address - Phone:662-534-4774
Mailing Address - Fax:665-534-4775
Practice Address - Street 1:498 W BANKHEAD ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3319
Practice Address - Country:US
Practice Address - Phone:662-534-4774
Practice Address - Fax:665-534-4775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS02138/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440688Medicaid
MS03837896Medicaid
2123079OtherPK