1295397248 NPI number — SGSP, INC

Table of content: (NPI 1295397248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295397248 NPI number — SGSP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SGSP, 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:
LYMAN PHARMACY 49
Provider Other Organization Name Type Code:
3
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:
1295397248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20117 BOX CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAUCIER
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39574-8702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-234-6236
Provider Business Mailing Address Fax Number:
228-831-9951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12372 HIGHWAY 49
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39503-2741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-234-6236
Provider Business Practice Location Address Fax Number:
228-831-9951
Provider Enumeration Date:
06/30/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GALLOTTE
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
SUMMER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
228-234-6236

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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