Provider Demographics
NPI:1144383613
Name:POMANK VENTURES LLC
Entity Type:Organization
Organization Name:POMANK VENTURES LLC
Other - Org Name:FAIRVIEW PHARMACY & COMPOUNDING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:R. PH.
Authorized Official - Prefix:
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-544-4871
Mailing Address - Street 1:500 KATIE AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-4380
Mailing Address - Country:US
Mailing Address - Phone:601-544-4871
Mailing Address - Fax:601-583-2298
Practice Address - Street 1:500 KATIE AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4380
Practice Address - Country:US
Practice Address - Phone:601-544-4871
Practice Address - Fax:601-583-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01066/1.1333600000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158949OtherPK
MS00095079Medicaid