Provider Demographics
NPI:1659606663
Name:VICKSBURG SPECIAL CARE PHARMACY AND COMPOUNDING LLC
Entity Type:Organization
Organization Name:VICKSBURG SPECIAL CARE PHARMACY AND COMPOUNDING LLC
Other - Org Name:ASPIRE RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:601-983-1239
Mailing Address - Street 1:1485 LIVINGSTON LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-8004
Mailing Address - Country:US
Mailing Address - Phone:601-326-7347
Mailing Address - Fax:601-982-7103
Practice Address - Street 1:4079 PEMBERTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5580
Practice Address - Country:US
Practice Address - Phone:601-636-5555
Practice Address - Fax:601-638-1564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS08249/1.13336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122108OtherPK
LA123555Medicaid