Provider Demographics
NPI:1548301062
Name:CITY DRUG STORE, INC.
Entity type:Organization
Organization Name:CITY DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:HORACE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-222-1131
Mailing Address - Street 1:224 S THREE NOTCH ST
Mailing Address - Street 2:POST OFFICE BOX 909
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-3710
Mailing Address - Country:US
Mailing Address - Phone:334-222-1131
Mailing Address - Fax:334-222-6212
Practice Address - Street 1:224 S THREE NOTCH ST
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420
Practice Address - Country:US
Practice Address - Phone:334-222-1131
Practice Address - Fax:334-222-6212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-03-31
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2011-03-31
Provider Licenses
StateLicense IDTaxonomies
AL111849183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0103731OtherNCPDP ID
AL100000391Medicaid
AL111849OtherALABAMA PHARMACY LICENSE
AL100000391Medicaid