Provider Demographics
NPI:1740599091
Name:WINN IMMUNIZATION SERVICES
Entity Type:Organization
Organization Name:WINN IMMUNIZATION SERVICES
Other - Org Name:WINN PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:WINN
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-442-4527
Mailing Address - Street 1:149 PILGRIM RD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-2650
Mailing Address - Country:US
Mailing Address - Phone:601-442-4527
Mailing Address - Fax:601-442-4490
Practice Address - Street 1:149 PILGRIM RD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-2650
Practice Address - Country:US
Practice Address - Phone:601-442-4527
Practice Address - Fax:601-442-4490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINN ENTERPRISES P.C.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0414901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440611Medicaid