Provider Demographics
NPI:1912452921
Name:SPORTS MEDICINE PHARMACY LLC
Entity type:Organization
Organization Name:SPORTS MEDICINE PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:MCLAURIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-949-9105
Mailing Address - Street 1:4506 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9583
Mailing Address - Country:US
Mailing Address - Phone:601-949-9105
Mailing Address - Fax:601-351-5974
Practice Address - Street 1:4506 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9583
Practice Address - Country:US
Practice Address - Phone:601-949-9105
Practice Address - Fax:601-351-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0002X, 3336S0011X
MS14908333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06600515Medicaid
2162491OtherPK