Provider Demographics
NPI:1295220598
Name:MS STATE VETERANS HOME KOSCIUSKO
Entity Type:Organization
Organization Name:MS STATE VETERANS HOME KOSCIUSKO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:POCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-290-3000
Mailing Address - Street 1:310 AUTUMN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3242
Mailing Address - Country:US
Mailing Address - Phone:662-290-3000
Mailing Address - Fax:662-289-7824
Practice Address - Street 1:310 AUTUMN RIDGE DR
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3242
Practice Address - Country:US
Practice Address - Phone:662-290-3000
Practice Address - Fax:662-289-7824
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MS STATE VETERANS AFFAIRS BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-28
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS806314000000X
3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No3336I0012XSuppliersPharmacyInstitutional Pharmacy