Provider Demographics
NPI:1790818532
Name:MEMORIAL HOSPITAL OF GULFPORT
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL OF GULFPORT
Other - Org Name:MHG EMPLOYEE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EMPLOYEE PHARMACY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KWITZKY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:228-865-3045
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:4500 13TH ST
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-865-3525
Mailing Address - Fax:228-865-3618
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-865-3525
Practice Address - Fax:228-865-3618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0155003.1OtherSTATE LICENSE
MS20027Medicaid
MS20027Medicaid
MS20027Medicaid