Provider Demographics
NPI:1487741203
Name:PROFESSIONAL PHARMACY SERVICES, INC
Entity type:Organization
Organization Name:PROFESSIONAL PHARMACY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:VAL
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLDEVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-624-6592
Mailing Address - Street 1:260 DELTA AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-4213
Mailing Address - Country:US
Mailing Address - Phone:662-624-6592
Mailing Address - Fax:
Practice Address - Street 1:260 DELTA AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-4213
Practice Address - Country:US
Practice Address - Phone:662-624-6592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS02101183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030537Medicaid
MS2516029OtherNCPDP
MS00440863Medicaid
MS00440863Medicaid