Provider Demographics
NPI:1215032420
Name:PETAL DRUG COMPANY, INC.
Entity Type:Organization
Organization Name:PETAL DRUG COMPANY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:RATCLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-545-3141
Mailing Address - Street 1:201 OLD RICHTON RD
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-2943
Mailing Address - Country:US
Mailing Address - Phone:601-545-3141
Mailing Address - Fax:601-544-7404
Practice Address - Street 1:201 OLD RICHTON RD
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-2943
Practice Address - Country:US
Practice Address - Phone:601-545-3141
Practice Address - Fax:601-544-7404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE08925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2506496OtherNABP NUMBER
MS00033642Medicaid