Provider Demographics
NPI:1548337025
Name:COLDWATER PHARMACY INC
Entity type:Organization
Organization Name:COLDWATER PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-622-7441
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-0309
Mailing Address - Country:US
Mailing Address - Phone:662-622-7441
Mailing Address - Fax:662-622-7004
Practice Address - Street 1:421 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MS
Practice Address - Zip Code:38618-3915
Practice Address - Country:US
Practice Address - Phone:662-622-7441
Practice Address - Fax:662-622-7004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 332B00000X
MS00625/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127928OtherPK
MS00094226Medicaid
MS00440543Medicaid
5267240001Medicare NSC