Provider Demographics
NPI:1699182444
Name:PHARMACY GROUP OF MISSISSIPPI, LLC
Entity Type:Organization
Organization Name:PHARMACY GROUP OF MISSISSIPPI, LLC
Other - Org Name:PHARMACY PARTNERS OF MISSISSIPPI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-499-2460
Mailing Address - Street 1:136 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8701
Mailing Address - Country:US
Mailing Address - Phone:601-499-2460
Mailing Address - Fax:
Practice Address - Street 1:136 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-8701
Practice Address - Country:US
Practice Address - Phone:601-499-2460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-14
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy