Provider Demographics
NPI:1730186982
Name:MISSISSIPPI DISCOUNT DRUGS OF CLINTON INC
Entity type:Organization
Organization Name:MISSISSIPPI DISCOUNT DRUGS OF CLINTON INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MGR AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:ACCOUNTING
Authorized Official - Phone:601-924-5212
Mailing Address - Street 1:224 CLINTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5126
Mailing Address - Country:US
Mailing Address - Phone:601-924-5212
Mailing Address - Fax:601-924-4649
Practice Address - Street 1:224 CLINTON BLVD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5126
Practice Address - Country:US
Practice Address - Phone:601-924-5212
Practice Address - Fax:601-924-4649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MS00837/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0330602Medicaid
2501561OtherNCPDP PROVIDER IDENTIFICATION NUMBER
5832640001Medicare NSC