Provider Demographics
NPI:1518040500
Name:REGION IV MH MR COMMISSION PHCY
Entity Type:Organization
Organization Name:REGION IV MH MR COMMISSION PHCY
Other - Org Name:REGION IV MH MR COMMISSION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-286-9883
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-0716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301B E CHAMBERS DR
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829
Practice Address - Country:US
Practice Address - Phone:662-728-3174
Practice Address - Fax:662-728-3159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
MS06596/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2047211OtherPK
MS05052355Medicaid