Provider Demographics
NPI:1215019443
Name:DUTCH PHARMACIES INC
Entity Type:Organization
Organization Name:DUTCH PHARMACIES INC
Other - Org Name:FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-329-0054
Mailing Address - Street 1:1214 HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2142
Mailing Address - Country:US
Mailing Address - Phone:662-329-0054
Mailing Address - Fax:662-329-0081
Practice Address - Street 1:1214 HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2142
Practice Address - Country:US
Practice Address - Phone:662-329-0054
Practice Address - Fax:662-329-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS02352/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330011Medicaid
2045372OtherPK
4371030001Medicare NSC