Provider Demographics
NPI:1285670083
Name:CITY DRUG STORE INC
Entity Type:Organization
Organization Name:CITY DRUG STORE INC
Other - Org Name:CITY DRUG STORE OF HENDERSON TN INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-989-2166
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-0224
Mailing Address - Country:US
Mailing Address - Phone:731-989-2166
Mailing Address - Fax:731-989-9685
Practice Address - Street 1:118 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-2335
Practice Address - Country:US
Practice Address - Phone:731-989-2166
Practice Address - Fax:731-989-9685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TN04263336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095494OtherPK
TN1452928Medicaid
0448610001Medicare NSC