Provider Demographics
NPI:1922087493
Name:SMITHVILLE PHARMACY
Entity Type:Organization
Organization Name:SMITHVILLE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:S.
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:662-651-5377
Mailing Address - Street 1:63432 HIGHWAY 25 N
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38870-7763
Mailing Address - Country:US
Mailing Address - Phone:662-651-5377
Mailing Address - Fax:662-651-5379
Practice Address - Street 1:63432 HIGHWAY 25 N
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MS
Practice Address - Zip Code:38870-7763
Practice Address - Country:US
Practice Address - Phone:662-651-5377
Practice Address - Fax:662-651-5379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04541/01.1333600000X
MSCS-04541/01.1333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440615Medicaid
MS00440615Medicaid
MS=========AOtherBCBS OF MS LAB
MS00330487Medicare ID - Type UnspecifiedMS MEDICAID RX SUPPLIER