Provider Demographics
NPI:1003083544
Name:BRISTER BROTHERS PHARMACY DME
Entity Type:Organization
Organization Name:BRISTER BROTHERS PHARMACY DME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-226-1642
Mailing Address - Street 1:1117 SUNSET DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4080
Mailing Address - Country:US
Mailing Address - Phone:662-226-1642
Mailing Address - Fax:662-226-8585
Practice Address - Street 1:1117 SUNSET DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4080
Practice Address - Country:US
Practice Address - Phone:662-226-1642
Practice Address - Fax:662-226-8585
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRISTER BROTHERS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440562Medicaid