Provider Demographics
NPI:1093883233
Name:MEDI CENTER PHARMACY
Entity Type:Organization
Organization Name:MEDI CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDRIC
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOW
Authorized Official - Suffix:
Authorized Official - Credentials:PHRM
Authorized Official - Phone:662-624-6561
Mailing Address - Street 1:1629 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6617
Mailing Address - Country:US
Mailing Address - Phone:662-624-6561
Mailing Address - Fax:662-624-6562
Practice Address - Street 1:1629 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6617
Practice Address - Country:US
Practice Address - Phone:662-624-6561
Practice Address - Fax:662-627-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01632011333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00095109Medicaid
2511043OtherOTHER ID NUMBER-COMMERCIAL NUMBER