Organization
MIDSOUTH MEDICAL SPECIALTIES LLC
Active
Other names
Super Drugs
Organization subpart
No
Provider details
NPI number
Authorized official
JAKE O'BANNON (PHARMACIST)
(662) 280-7455
Entity
Organization
Contact information
Practice address
1433 GOODMAN RD W, HORN LAKE, MS 38637-1404
(901) 674-3148
Mailing address
1433 GOODMAN RD W, HORN LAKE, MS 38637-1404
(662) 280-7455
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
—
—
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02434788
—
MS
Enumeration date
11/08/2021
Last updated
11/08/2021
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