Provider Demographics
NPI:1639277957
Name:UNIVERSITY OF MISSISSIPPI
Entity Type:Organization
Organization Name:UNIVERSITY OF MISSISSIPPI
Other - Org Name:STUDENT HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:662-915-5279
Mailing Address - Street 1:153 REBEL DRIVE
Mailing Address - Street 2:HARRISON BLDG
Mailing Address - City:UNIVERSITY
Mailing Address - State:MS
Mailing Address - Zip Code:38677-1848
Mailing Address - Country:US
Mailing Address - Phone:662-915-5279
Mailing Address - Fax:662-915-5292
Practice Address - Street 1:153 REBEL DRIVE
Practice Address - Street 2:HARRISON BLDG
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677-1848
Practice Address - Country:US
Practice Address - Phone:662-915-5279
Practice Address - Fax:662-915-5292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF MISSISSIPPI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0222902SU333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2517083OtherNABP
MSBU2570340OtherDEA