1477655819 NPI number — MR DISCOUNT DRUGS AT RUSH MEDICAL

Table of content: (NPI 1477655819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477655819 NPI number — MR DISCOUNT DRUGS AT RUSH MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MR DISCOUNT DRUGS AT RUSH MEDICAL
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:
MR DISCOUNT DRUGS AT RUSH MEDICAL GROUP
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:
1477655819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4820 POPLAR SPRINGS DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39305-2678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-703-9642
Provider Business Mailing Address Fax Number:
601-703-9415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39301-4158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-703-9642
Provider Business Practice Location Address Fax Number:
601-703-9415
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALDRON
Authorized Official First Name:
DON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-482-8121

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2345012 , 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: 2045363 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00330006 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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