Provider Demographics
NPI:1417090093
Name:UNIVERSITY PAVILION PHARMACY
Entity type:Organization
Organization Name:UNIVERSITY PAVILION PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:HARTNESS
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-984-2058
Mailing Address - Street 1:1410 E WOODROW WILSON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-2058
Mailing Address - Fax:601-984-2063
Practice Address - Street 1:1410 E WOODROW WILSON DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-2058
Practice Address - Fax:601-984-2063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS021883336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS30158Medicaid