Provider Demographics
NPI:1356401491
Name:PREMIER PHARMACEUTICAL SERVICES, LLC
Entity type:Organization
Organization Name:PREMIER PHARMACEUTICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-888-7176
Mailing Address - Street 1:PO BOX 1051
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39669-1051
Mailing Address - Country:US
Mailing Address - Phone:601-888-7176
Mailing Address - Fax:601-888-7134
Practice Address - Street 1:1348 US HIGHWAY 61 S
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:MS
Practice Address - Zip Code:39669-4560
Practice Address - Country:US
Practice Address - Phone:601-888-7176
Practice Address - Fax:601-888-7134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05058 11.1332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1434850Medicaid
MS00440778Medicaid
MS0330599Medicaid
LA1268453Medicaid
LA1268453Medicaid