Provider Demographics
NPI:1154465912
Name:YALOBUSHA GENERAL HOSPITAL
Entity Type:Organization
Organization Name:YALOBUSHA GENERAL HOSPITAL
Other - Org Name:THE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:EMBRY
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:662-675-2775
Mailing Address - Street 1:31 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:COFFEEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38922-3352
Mailing Address - Country:US
Mailing Address - Phone:662-675-2775
Mailing Address - Fax:662-675-8477
Practice Address - Street 1:31 FRONT ST
Practice Address - Street 2:
Practice Address - City:COFFEEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38922-3352
Practice Address - Country:US
Practice Address - Phone:662-675-2775
Practice Address - Fax:662-675-8477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MS016050113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2050691OtherPK
MS00093220Medicaid