1659448934 NPI number — SPECIALTY SERVICES, INC.

Table of content: (NPI 1659448934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659448934 NPI number — SPECIALTY SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALTY SERVICES, 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:
1659448934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1627 HIGHWAY 61 JONESTOWN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COAHOMA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38617-9790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-358-4500
Provider Business Mailing Address Fax Number:
662-358-4507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1627 HIGHWAY 61 JONESTOWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COAHOMA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38617-9790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-358-4500
Provider Business Practice Location Address Fax Number:
662-358-4507
Provider Enumeration Date:
11/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WEILAND
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER PHARMACIST
Authorized Official Telephone Number:
662-358-4500

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  04428/02.0 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: 04428/02.0 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: OS01422 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 04428 02.0 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 04428 02.0 , 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: 0330666 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138725733 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142601407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0440634 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138724716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".