1548395825 NPI number — SHELBY DRUG CO INC HWY 61 SOUTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548395825 NPI number — SHELBY DRUG CO INC HWY 61 SOUTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELBY DRUG CO INC HWY 61 SOUTH
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:
1548395825
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1211 BROADWAY HWY 61 SO
Provider Second Line Business Mailing Address:
PO BOX 1105
Provider Business Mailing Address City Name:
SHELBY
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-398-7487
Provider Business Mailing Address Fax Number:
662-398-7109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1211 BROADWAY HWY 61 SO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38774
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-398-7487
Provider Business Practice Location Address Fax Number:
662-398-7109
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
EDDIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
662-624-2526

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  00798/01.1 , 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: 2507119 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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