1417965740 NPI number — KING AND MCNULTY, LLC

Table of content: (NPI 1417965740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417965740 NPI number — KING AND MCNULTY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KING AND MCNULTY, LLC
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:
DIXON DISCOUNT PHARMACY, GLOSTER DISCOUNT PHARMACY
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:
1417965740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAGEE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39111-1100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-849-6440
Provider Business Mailing Address Fax Number:
601-849-7557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
434 B SOUTH CAPTAIN GLOSTER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLOSTER
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-225-7907
Provider Business Practice Location Address Fax Number:
601-225-7906
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCNULTY
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
601-849-4112

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  06673/01.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00639091 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2586228 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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