1205802980 NPI number — CITY DRUGS OF CRYSTAL SPRINGS, INC.

Table of content: (NPI 1205802980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205802980 NPI number — CITY DRUGS OF CRYSTAL SPRINGS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY DRUGS OF CRYSTAL SPRINGS, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1205802980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 BO BO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRYSTAL SPRINGS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39059-2741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-892-4121
Provider Business Mailing Address Fax Number:
601-892-1598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 BO BO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRYSTAL SPRINGS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39059-2741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-892-4121
Provider Business Practice Location Address Fax Number:
601-892-1598
Provider Enumeration Date:
02/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
REAGAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
601-892-4121

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  01756/01.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X , with the licence number: 01756/1.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00030165 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2501624 . This is a "NCPDP NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com