Provider Demographics
NPI:1558545210
Name:MAGNOLIA MANOR OF TUPELO
Entity Type:Organization
Organization Name:MAGNOLIA MANOR OF TUPELO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-842-6776
Mailing Address - Street 1:1514 COUNTY ROAD 41
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-0681
Mailing Address - Country:US
Mailing Address - Phone:662-842-6776
Mailing Address - Fax:662-842-6512
Practice Address - Street 1:1514 COUNTY ROAD 41
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-0681
Practice Address - Country:US
Practice Address - Phone:662-842-6776
Practice Address - Fax:662-842-6512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1000305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03083202Medicaid