Provider Demographics
NPI:1912452921
Name:SPORTS MEDICINE PHARMACY LLC
Entity Type:Organization
Organization Name:SPORTS MEDICINE PHARMACY LLC
Other - Org Name:SPORTS MEDICINE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CALVERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-672-1534
Mailing Address - Street 1:1325 E FORTIFICATION ST
Mailing Address - Street 2:PO BOX 16870
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2442
Mailing Address - Country:US
Mailing Address - Phone:601-354-4488
Mailing Address - Fax:769-777-6390
Practice Address - Street 1:1325 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2442
Practice Address - Country:US
Practice Address - Phone:601-354-4488
Practice Address - Fax:769-777-6390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14908333600000X, 3336S0011X
3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06600515Medicaid
2162491OtherPK