Provider Demographics
NPI:1770038382
Name:MCM OF MISSISSIPPI LLC
Entity Type:Organization
Organization Name:MCM OF MISSISSIPPI LLC
Other - Org Name:HOUSTON FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-542-8464
Mailing Address - Street 1:339 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-2322
Mailing Address - Country:US
Mailing Address - Phone:662-542-8464
Mailing Address - Fax:
Practice Address - Street 1:339 E MADISON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2322
Practice Address - Country:US
Practice Address - Phone:662-631-5055
Practice Address - Fax:662-631-5097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS14900/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08372765Medicaid
2163837OtherPK