Provider Demographics
NPI:1649323254
Name:EAST MISSISSIPPI STATE HOSPITAL
Entity type:Organization
Organization Name:EAST MISSISSIPPI STATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCKAY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-581-7818
Mailing Address - Street 1:1818 COLLEGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39307-5429
Mailing Address - Country:US
Mailing Address - Phone:601-581-7818
Mailing Address - Fax:601-581-7822
Practice Address - Street 1:1818 COLLEGE DRIVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-5429
Practice Address - Country:US
Practice Address - Phone:601-581-7818
Practice Address - Fax:601-581-7822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS283Q00000X
MS01108031333600000X, 3336L0003X, 3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No283Q00000XHospitalsPsychiatric Hospital
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330069Medicaid
2517689OtherNCPDP