Basic Information
| Provider Information | |||||||||
| NPI: | 1912452921 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPORTS MEDICINE PHARMACY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPORTS MEDICINE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | PO BOX 16870 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013544488 | ||||||||
| FaxNumber: | 7697776390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013544488 | ||||||||
| FaxNumber: | 7697776390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2016 | ||||||||
| LastUpdateDate: | 01/13/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CALVERT | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 6016721534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | 14908 | MS | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 06600515 | 05 | MS | MEDICAID | 2162491 | 01 | PK | OTHER |