Provider Demographics
NPI:1144749847
Name:CLINIC DRUG STORE, INC.
Entity Type:Organization
Organization Name:CLINIC DRUG STORE, INC.
Other - Org Name:PLAINS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:PINNELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:229-824-5255
Mailing Address - Street 1:103 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:GA
Mailing Address - Zip Code:31780
Mailing Address - Country:US
Mailing Address - Phone:229-824-5255
Mailing Address - Fax:229-824-3703
Practice Address - Street 1:103 MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:GA
Practice Address - Zip Code:31780
Practice Address - Country:US
Practice Address - Phone:229-824-5255
Practice Address - Fax:229-824-3703
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLINIC DRUG STORE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000033393AMedicaid