Provider Demographics
NPI:1992139711
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:D
Authorized Official - Last Name:O'BANNON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
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:901-262-4317
Mailing Address - Fax:662-510-0268
Practice Address - Street 1:185 W CENTER ST
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2268
Practice Address - Country:US
Practice Address - Phone:901-262-4317
Practice Address - Fax:662-510-0268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy