Provider Demographics
NPI:1114373586
Name:GENTEX PHARMA
Entity Type:Organization
Organization Name:GENTEX PHARMA
Other - Org Name:GENTEX PHARMA LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FORD
Authorized Official - Middle Name:JENNINGS
Authorized Official - Last Name:MUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:PERSON IN CHARGE
Authorized Official - Phone:870-243-1687
Mailing Address - Street 1:121 MARKETRIDGE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-6027
Mailing Address - Country:US
Mailing Address - Phone:601-990-9497
Mailing Address - Fax:601-510-9318
Practice Address - Street 1:121 MARKETRIDGE DR
Practice Address - Street 2:SUITE C
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-6027
Practice Address - Country:US
Practice Address - Phone:601-990-9497
Practice Address - Fax:601-510-9318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06677/6.1332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site