Provider Demographics
NPI:1275677890
Name:STATE OF MISSISSIPPI UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Entity Type:Organization
Organization Name:STATE OF MISSISSIPPI UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Other - Org Name:UNIVERSITY HOSPITAL & CLINIC HTC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:V
Authorized Official - Last Name:DANCER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-815-8902
Mailing Address - Street 1:350 W WOODROW WILSON AVE
Mailing Address - Street 2:501
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:601-815-3857
Mailing Address - Fax:601-815-8901
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:501
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-815-3857
Practice Address - Fax:601-815-8901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MISSISSIPPI UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-16
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06430333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01177235Medicaid