1003436569 NPI number — MOSBYS DRUG STORE

Table of content: (NPI 1003436569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003436569 NPI number — MOSBYS DRUG STORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSBYS DRUG STORE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOSBY'S DRUG STORE LTC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003436569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
195 E PEACE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39046-4519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-859-4212
Provider Business Mailing Address Fax Number:
601-859-4260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 E PEACE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39046-4937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-859-4212
Provider Business Practice Location Address Fax Number:
601-859-4260
Provider Enumeration Date:
04/24/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MURPHY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER/MEMBER
Authorized Official Telephone Number:
601-859-3939

Provider Taxonomy Codes

  • Taxonomy code: 183500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ADDRESS . This is a "ADDRESS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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