Provider Demographics
NPI:1255490611
Name:FAYETTE DISCOUNT DRUGS INC
Entity Type:Organization
Organization Name:FAYETTE DISCOUNT DRUGS INC
Other - Org Name:FAYETTE DISCOUNT DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:601-786-3391
Mailing Address - Street 1:1418 MAIN ST
Mailing Address - Street 2:PO BOX 127
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069
Mailing Address - Country:US
Mailing Address - Phone:601-786-3391
Mailing Address - Fax:
Practice Address - Street 1:1418 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069-9802
Practice Address - Country:US
Practice Address - Phone:601-786-3391
Practice Address - Fax:601-786-3397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS061173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2050543OtherPK
MS01379003Medicaid