Provider Demographics
NPI:1649419532
Name:STATE OF MISSISSIPPI-UNIVERSITY OF MISSISSIPPI MED CTR
Entity Type:Organization
Organization Name:STATE OF MISSISSIPPI-UNIVERSITY OF MISSISSIPPI MED CTR
Other - Org Name:UMHC CARE CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TODARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-984-2754
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:H120
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-1686
Mailing Address - Fax:601-815-1689
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:H120
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-1686
Practice Address - Fax:601-815-1689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07796/05.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06300271Medicaid
2119027OtherPK