Provider Demographics
NPI:1457505315
Name:MS STATE DEPT OF HEALTH PHARMACY
Entity Type:Organization
Organization Name:MS STATE DEPT OF HEALTH PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-713-3457
Mailing Address - Street 1:3156 LAWSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-5754
Mailing Address - Country:US
Mailing Address - Phone:601-713-3457
Mailing Address - Fax:601-364-2670
Practice Address - Street 1:3156 LAWSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-5754
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:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01085 05.1251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare