Provider Demographics
NPI:1720368541
Name:MAGNOLIA SPECIALTY PHARMACY INC
Entity Type:Organization
Organization Name:MAGNOLIA SPECIALTY PHARMACY INC
Other - Org Name:MAGNOLIA SPECIALTY PHARMACY INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-606-0252
Mailing Address - Street 1:16 KEYSTONE DR STE B
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-6121
Mailing Address - Country:US
Mailing Address - Phone:877-871-3935
Mailing Address - Fax:888-990-0575
Practice Address - Street 1:16 KEYSTONE DR STE B
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-6121
Practice Address - Country:US
Practice Address - Phone:877-871-3935
Practice Address - Fax:888-990-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS090873336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131699OtherPK