Provider Demographics
NPI:1285639906
Name:TYSON DRUG INC
Entity Type:Organization
Organization Name:TYSON DRUG INC
Other - Org Name:POTTS CAMP PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMENICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-252-2321
Mailing Address - Street 1:41 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:POTTS CAMP
Mailing Address - State:MS
Mailing Address - Zip Code:38659-9531
Mailing Address - Country:US
Mailing Address - Phone:662-333-7782
Mailing Address - Fax:662-333-4095
Practice Address - Street 1:41 S CENTER ST
Practice Address - Street 2:
Practice Address - City:POTTS CAMP
Practice Address - State:MS
Practice Address - Zip Code:38659-9531
Practice Address - Country:US
Practice Address - Phone:662-333-7782
Practice Address - Fax:662-333-4095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS02436/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330080Medicaid
2045412OtherPK