Provider Demographics
NPI:1922374420
Name:MAGNOLIA ANALYTICAL, LLC
Entity Type:Organization
Organization Name:MAGNOLIA ANALYTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENDUSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-606-6366
Mailing Address - Street 1:1 LINCOLN PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 LINCOLN PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3262
Practice Address - Country:US
Practice Address - Phone:601-579-4466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory