Provider Demographics
NPI:1184919268
Name:FIRST PHARMACY SERVICES 5
Entity type:Organization
Organization Name:FIRST PHARMACY SERVICES 5
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-349-3300
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:POPE
Mailing Address - State:MS
Mailing Address - Zip Code:38658-0047
Mailing Address - Country:US
Mailing Address - Phone:662-349-3300
Mailing Address - Fax:662-349-3311
Practice Address - Street 1:6888 GOODMAN RD STE 122
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-8761
Practice Address - Country:US
Practice Address - Phone:662-349-3300
Practice Address - Fax:662-349-3311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X, 3336C0003X, 3336M0003X, 3336S0011X
MS13864/4.13336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149277OtherPK