Provider Demographics
NPI:1558894790
Name:MIDSOUTH MEDICAL SPECIALTIES, LLC
Entity Type:Organization
Organization Name:MIDSOUTH MEDICAL SPECIALTIES, LLC
Other - Org Name:OAK PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BANNON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-449-7876
Mailing Address - Street 1:185 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-2268
Mailing Address - Country:US
Mailing Address - Phone:662-449-7876
Mailing Address - Fax:662-449-7970
Practice Address - Street 1:105 SAWTOOTH OAK ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7160
Practice Address - Country:US
Practice Address - Phone:501-623-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR206973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy