Provider Demographics
NPI:1952783078
Name:MOM 2 BE, LLC
Entity Type:Organization
Organization Name:MOM 2 BE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:LACY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-570-4991
Mailing Address - Street 1:449 WILKINS WISE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1756
Mailing Address - Country:US
Mailing Address - Phone:662-570-4991
Mailing Address - Fax:662-570-4992
Practice Address - Street 1:449 WILKINS WISE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1756
Practice Address - Country:US
Practice Address - Phone:662-570-4991
Practice Address - Fax:662-570-4992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site