Provider Demographics
NPI:1497852602
Name:MEDICAL PLAZA ON ALCORN LLC
Entity Type:Organization
Organization Name:MEDICAL PLAZA ON ALCORN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-286-6991
Mailing Address - Street 1:111 ALCORN DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9359
Mailing Address - Country:US
Mailing Address - Phone:662-286-6991
Mailing Address - Fax:662-287-8087
Practice Address - Street 1:111 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9359
Practice Address - Country:US
Practice Address - Phone:662-286-6991
Practice Address - Fax:662-287-8087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0313501.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440678Medicaid
MS00095265Medicaid
MS0327840001Medicare NSC