Provider Demographics
NPI:1114047081
Name:BAKERS PHARMACY INC
Entity Type:Organization
Organization Name:BAKERS PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-833-6361
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39602-0236
Mailing Address - Country:US
Mailing Address - Phone:601-833-6361
Mailing Address - Fax:601-833-3125
Practice Address - Street 1:212 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-3040
Practice Address - Country:US
Practice Address - Phone:601-833-6361
Practice Address - Fax:601-833-3125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00104 01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030171Medicaid