Provider Demographics
NPI:1063497972
Name:VERNON DISCOUNT DRUG INC
Entity Type:Organization
Organization Name:VERNON DISCOUNT DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:850-535-2803
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:FL
Mailing Address - Zip Code:32462-0505
Mailing Address - Country:US
Mailing Address - Phone:850-535-2803
Mailing Address - Fax:850-535-0150
Practice Address - Street 1:3248 MAIN ST
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:FL
Practice Address - Zip Code:32462-2223
Practice Address - Country:US
Practice Address - Phone:850-535-2803
Practice Address - Fax:850-535-2803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH11020333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1064219Medicare UPIN