1366004731 NPI number — SUMRALL DRUG STORE LLC

Table of content: (NPI 1366004731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366004731 NPI number — SUMRALL DRUG STORE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMRALL DRUG STORE 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:
SUMRALL DRUG STORE LONG TERM CARE
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:
1366004731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMRALL
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39482-0120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-758-4243
Provider Business Mailing Address Fax Number:
601-758-4999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1109 HWY 42
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMRALL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-758-4243
Provider Business Practice Location Address Fax Number:
601-758-4999
Provider Enumeration Date:
07/05/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HADEN
Authorized Official First Name:
TASHA
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PHARMACIST/OWNER
Authorized Official Telephone Number:
601-758-4243

Provider Taxonomy Codes

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

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





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