Provider Demographics
NPI:1770158339
Name:GOOD SHEPHERD MEDICAL/DENTAL CLINIC
Entity type:Organization
Organization Name:GOOD SHEPHERD MEDICAL/DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLGAMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-426-2001
Mailing Address - Street 1:PO BOX 2704
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39442-2704
Mailing Address - Country:US
Mailing Address - Phone:601-426-2001
Mailing Address - Fax:601-426-2002
Practice Address - Street 1:207 S 11TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4314
Practice Address - Country:US
Practice Address - Phone:601-426-2001
Practice Address - Fax:601-426-2002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy