Provider Demographics
NPI:1316983869
Name:DIVERSIFIED INFUSIONCARE SOLUTIONS
Entity type:Organization
Organization Name:DIVERSIFIED INFUSIONCARE SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-320-9696
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39760-2394
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2164
Practice Address - Country:US
Practice Address - Phone:662-320-9696
Practice Address - Fax:662-320-9616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251F00000X, 3336C0003X, 3336H0001X, 3336S0011X
MS0463302DT333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251F00000XAgenciesHome Infusion
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440638Medicaid
2519710OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS0330522Medicaid
2519710OtherOTHER ID NUMBER-COMMERCIAL NUMBER