Provider Demographics
NPI:1740202571
Name:BOSWELL REGIONAL CENTER
Entity Type:Organization
Organization Name:BOSWELL REGIONAL CENTER
Other - Org Name:BOSWELL REGIONAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-867-5000
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1049 HWY 149
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111
Practice Address - Country:US
Practice Address - Phone:601-867-5000
Practice Address - Fax:601-867-5236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS014730463336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045521OtherPK
MS00030185Medicaid