Provider Demographics
NPI:1962999789
Name:STATE VETERANS AFFAIRS BOARD
Entity type:Organization
Organization Name:STATE VETERANS AFFAIRS BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:VELEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:601-353-6142
Mailing Address - Street 1:4607 LINDBERGH DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-3855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4607 LINDBERGH DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-3855
Practice Address - Country:US
Practice Address - Phone:601-353-6142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE VETERANS AFFAIRS BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-17
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No3336I0012XSuppliersPharmacyInstitutional Pharmacy