Provider Demographics
NPI:1013167824
Name:PHARMEDIUM SERVICES LLC
Entity Type:Organization
Organization Name:PHARMEDIUM SERVICES LLC
Other - Org Name:PHARMEDIUM SERVICES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-846-5969
Mailing Address - Street 1:913 N DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2106
Mailing Address - Country:US
Mailing Address - Phone:662-846-5969
Mailing Address - Fax:662-864-2614
Practice Address - Street 1:913 N DAVIS AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2106
Practice Address - Country:US
Practice Address - Phone:662-846-5969
Practice Address - Fax:662-864-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05336/02.03336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2587357OtherNCPDP PROVIDER IDENTIFICATION NUMBER