Provider Demographics
NPI:1184833741
Name:BORROUMS DRUG STORE
Entity Type:Organization
Organization Name:BORROUMS DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:BORROUM
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:662-286-3361
Mailing Address - Street 1:604 E WALDRON ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-4863
Mailing Address - Country:US
Mailing Address - Phone:662-286-3361
Mailing Address - Fax:662-286-3361
Practice Address - Street 1:604 E WALDRON ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-4863
Practice Address - Country:US
Practice Address - Phone:662-286-3361
Practice Address - Fax:662-286-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0020201.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030473Medicaid