Provider Demographics
NPI:1932144342
Name:STATE OF MISSISSIPPI-UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Entity Type:Organization
Organization Name:STATE OF MISSISSIPPI-UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
Other - Org Name:UNIVERSITY HOSPITAL & CLINICS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DIRECTOR OF PHARMACY
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DANCER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:601-815-8902
Mailing Address - Street 1:350 W WOODROW WILSON AVE
Mailing Address - Street 2:SUITE 501
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:601-815-3857
Mailing Address - Fax:601-815-8901
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-815-3857
Practice Address - Fax:601-815-8901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MISSISSIPPI-UNIVERSITY OF MISSISSIPPI MEDICAL CENTER UNIVERSI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-19
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04116333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0330385Medicaid
MS0330385Medicaid