Provider Demographics
NPI:1982761367
Name:NORTHEAST MENTAL HEALTH MENTAL RETARDATION COMMISSION
Entity Type:Organization
Organization Name:NORTHEAST MENTAL HEALTH MENTAL RETARDATION COMMISSION
Other - Org Name:LIFECORE PHARMACY, AMORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PHARMACY DIVISION
Authorized Official - Prefix:
Authorized Official - First Name:VAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS OF PHARMACY
Authorized Official - Phone:662-634-4347
Mailing Address - Street 1:317 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-3420
Mailing Address - Country:US
Mailing Address - Phone:662-634-4347
Mailing Address - Fax:662-256-5567
Practice Address - Street 1:317 MAIN ST N
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-3420
Practice Address - Country:US
Practice Address - Phone:662-634-4347
Practice Address - Fax:662-256-5567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS07162/5.23336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2047457OtherPK
MS05123737Medicaid