Provider Demographics
NPI:1811009814
Name:MEDI START INC
Entity Type:Organization
Organization Name:MEDI START INC
Other - Org Name:MEDISTART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:
Authorized Official - Last Name:MOKHTAR
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-899-5621
Mailing Address - Street 1:3188 W NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3188 W NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4516
Practice Address - Country:US
Practice Address - Phone:601-321-8883
Practice Address - Fax:601-321-0981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MS06950113336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2586660OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS06133579Medicaid
2586660OtherOTHER ID NUMBER