Provider Demographics
NPI:1437180452
Name:YAZOO MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:YAZOO MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA
Authorized Official - Phone:662-746-5677
Mailing Address - Street 1:805 1/2 EAST 15TH STREET
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194
Mailing Address - Country:US
Mailing Address - Phone:662-746-5677
Mailing Address - Fax:662-746-5676
Practice Address - Street 1:805 1/2 EAST 15TH STREET
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194
Practice Address - Country:US
Practice Address - Phone:662-746-5677
Practice Address - Fax:662-746-5676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS332B00000X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00040344Medicaid
MS000012696OtherBLUE CROSS/BLUE SHIELD ID
MS=========OtherTAX ID #
MS00040344Medicaid