Provider Demographics
NPI:1871526582
Name:SOUTHWEST PHARMACY, INC
Entity type:Organization
Organization Name:SOUTHWEST PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, FACA, FIACP
Authorized Official - Phone:601-684-8070
Mailing Address - Street 1:312 MARION AVE # A
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2708
Mailing Address - Country:US
Mailing Address - Phone:601-684-8070
Mailing Address - Fax:601-684-7249
Practice Address - Street 1:312 MARION AVE # A
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2708
Practice Address - Country:US
Practice Address - Phone:601-684-8070
Practice Address - Fax:601-684-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS02002/11.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00045113Medicaid
MS00045113Medicaid