1760424659 NPI number — JIM BAIN'S COMPOUNDING PHARMACY

Table of content: (NPI 1760424659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760424659 NPI number — JIM BAIN'S COMPOUNDING PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JIM BAIN'S COMPOUNDING PHARMACY
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:
1760424659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7241
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38802-7241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-844-4530
Provider Business Mailing Address Fax Number:
662-844-4537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
367 N GLOSTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUPELO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38804-3633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-844-4530
Provider Business Practice Location Address Fax Number:
662-844-4537
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAIN
Authorized Official First Name:
JIM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHARAMIST
Authorized Official Telephone Number:
662-844-4530

Provider Taxonomy Codes

  • Taxonomy code: 183700000X , with the licence number:  2101-1513-3453-350 , 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: 2586139 . This is a "NCPDP" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com