Provider Demographics
NPI:1376606582
Name:MISSISSIPP STATE DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:MISSISSIPP STATE DEPARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY TECHNICIAN
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:SHANEE
Authorized Official - Last Name:LIDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-713-3457
Mailing Address - Street 1:3156 LAWSON STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213
Mailing Address - Country:US
Mailing Address - Phone:601-713-3457
Mailing Address - Fax:601-364-2670
Practice Address - Street 1:3156 LAWSON STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213
Practice Address - Country:US
Practice Address - Phone:601-713-3457
Practice Address - Fax:601-364-2670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01085 05.1251K00000X
MS0108505.13336C0002X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No251K00000XAgenciesPublic Health or Welfare
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2517196OtherNCPDP
MS094171001Medicare ID - Type Unspecified