Provider Demographics
NPI:1932476280
Name:PUCKETT MEDICAL CLINIC
Entity Type:Organization
Organization Name:PUCKETT MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVELIN
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:601-824-9490
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:PUCKETT
Mailing Address - State:MS
Mailing Address - Zip Code:39151-0366
Mailing Address - Country:US
Mailing Address - Phone:601-824-9490
Mailing Address - Fax:691-824-9533
Practice Address - Street 1:6455 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-7536
Practice Address - Country:US
Practice Address - Phone:601-824-9490
Practice Address - Fax:601-824-9533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR633283261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service