Provider Demographics
NPI:1841395191
Name:POTOTOC HEALTH SERVICES INC
Entity Type:Organization
Organization Name:POTOTOC HEALTH SERVICES INC
Other - Org Name:PONTOTOC HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-377-3978
Mailing Address - Street 1:176 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-3311
Mailing Address - Country:US
Mailing Address - Phone:662-488-7629
Mailing Address - Fax:662-488-7714
Practice Address - Street 1:176 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-3311
Practice Address - Country:US
Practice Address - Phone:662-488-7629
Practice Address - Fax:662-488-7714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS00902/3.13336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2043676OtherPK
MS0038938Medicaid