Provider Demographics
NPI:1346273588
Name:MACON CITY DRUG STORE, INC.
Entity Type:Organization
Organization Name:MACON CITY DRUG STORE, INC.
Other - Org Name:CITY DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-726-5143
Mailing Address - Street 1:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MS
Mailing Address - Zip Code:39341-0424
Mailing Address - Country:US
Mailing Address - Phone:662-726-5143
Mailing Address - Fax:662-726-5183
Practice Address - Street 1:3281 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341-2279
Practice Address - Country:US
Practice Address - Phone:662-726-5143
Practice Address - Fax:662-726-5183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
MS001250113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00039888Medicaid
2043292OtherPK
MS00440507Medicaid
0771340001Medicare NSC
2043292OtherPK