Provider Demographics
NPI:1346336757
Name:GRIFFIN'S DISCOUNT PHARMACY INC
Entity Type:Organization
Organization Name:GRIFFIN'S DISCOUNT PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FULLILOVE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:662-456-2501
Mailing Address - Street 1:339 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MS
Mailing Address - Zip Code:38851-2322
Mailing Address - Country:US
Mailing Address - Phone:662-456-2501
Mailing Address - Fax:662-456-4052
Practice Address - Street 1:339 E MADISON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2322
Practice Address - Country:US
Practice Address - Phone:662-456-2501
Practice Address - Fax:662-456-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01477333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030446Medicaid
2511954OtherNCPDP
MS01477OtherPHARMACY PERMIT