1174627459 NPI number — ANAZIA MEDICAL II, INC.

Table of content: MARY ELIZABETH BROADHEAD RPH (NPI 1245524420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174627459 NPI number — ANAZIA MEDICAL II, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANAZIA MEDICAL II, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174627459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 5TH AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCCOMB
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-249-0013
Provider Business Mailing Address Fax Number:
601-249-0592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1264 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FAYETTE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-786-0390
Provider Business Practice Location Address Fax Number:
601-786-0730
Provider Enumeration Date:
09/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANAZIA
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
O
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
601-249-0013

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  14997 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07753329 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com