Provider Demographics
NPI:1215349667
Name:MIDSOUTH MEDICAL SPECIALTIES, LLC
Entity type:Organization
Organization Name:MIDSOUTH MEDICAL SPECIALTIES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-262-4317
Mailing Address - Street 1:PO BOX 563
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-0563
Mailing Address - Country:US
Mailing Address - Phone:501-463-9922
Mailing Address - Fax:501-463-9925
Practice Address - Street 1:5500 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913
Practice Address - Country:US
Practice Address - Phone:014-639-9225
Practice Address - Fax:501-463-9925
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDSOUTH MEDICAL SPECIALTIES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-20
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR208246407Medicaid