Provider Demographics
NPI:1255677001
Name:MIDSOUTH MEDICAL SPECIALTIES, LLC
Entity type:Organization
Organization Name:MIDSOUTH MEDICAL SPECIALTIES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-449-9075
Mailing Address - Street 1:2260 HIGHWAY 515 SOUTH
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632
Mailing Address - Country:US
Mailing Address - Phone:662-449-9075
Mailing Address - Fax:662-449-3414
Practice Address - Street 1:2260 HIGHWAY 515 SOUTH
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632
Practice Address - Country:US
Practice Address - Phone:662-449-9075
Practice Address - Fax:662-449-3414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS118893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy