Provider Demographics
NPI:1811906357
Name:RICK QUINN
Entity type:Organization
Organization Name:RICK QUINN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KETCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-286-5747
Mailing Address - Street 1:504 ALCORN DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9392
Mailing Address - Country:US
Mailing Address - Phone:662-286-5747
Mailing Address - Fax:662-286-5508
Practice Address - Street 1:504 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9392
Practice Address - Country:US
Practice Address - Phone:662-286-5747
Practice Address - Fax:662-286-5508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03051/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0330175Medicaid