Provider Demographics
NPI:1265837983
Name:SINGING RIVER MENTAL HEALTH MENTAL RETARDATION SERVICES
Entity Type:Organization
Organization Name:SINGING RIVER MENTAL HEALTH MENTAL RETARDATION SERVICES
Other - Org Name:SINGING RIVER SERVICES REGION XIV
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:BRETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:ST ROMAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-497-0690
Mailing Address - Street 1:3407 SHAMROCK CT
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5337
Mailing Address - Country:US
Mailing Address - Phone:228-497-0690
Mailing Address - Fax:228-497-0794
Practice Address - Street 1:3407 SHAMROCK CT
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5337
Practice Address - Country:US
Practice Address - Phone:228-497-0690
Practice Address - Fax:228-497-0794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS14452/5.13336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01832567Medicaid
2153586OtherPK