Provider Demographics
NPI:1932127370
Name:DIVERSIFIED INFUSIONCARE SOLUTIONS, INC.
Entity Type:Organization
Organization Name:DIVERSIFIED INFUSIONCARE SOLUTIONS, INC.
Other - Org Name:DIVERSIFIED INFUSIONCARE SOLUTIONS VITAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-320-9696
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5047
Mailing Address - Country:US
Mailing Address - Phone:800-447-4095
Mailing Address - Fax:601-482-7490
Practice Address - Street 1:823 HIGHWAY 12 W
Practice Address - Street 2:SUITE E
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3593
Practice Address - Country:US
Practice Address - Phone:662-320-9696
Practice Address - Fax:662-320-9616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04633/02.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330522Medicaid
MS00440638Medicaid
MS00440638Medicaid