Provider Demographics
NPI:1023031713
Name:PEARL RIVER DRUG
Entity Type:Organization
Organization Name:PEARL RIVER DRUG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-795-4239
Mailing Address - Street 1:510 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-0000
Mailing Address - Country:US
Mailing Address - Phone:601-795-4239
Mailing Address - Fax:601-795-4941
Practice Address - Street 1:510 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470
Practice Address - Country:US
Practice Address - Phone:601-795-4239
Practice Address - Fax:601-795-4941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00558/01.13336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00033553Medicaid
MS00033553Medicaid