Provider Demographics
NPI:1407872666
Name:POLK'S CROSSGATE DISCOUNT DRUGS INC.
Entity Type:Organization
Organization Name:POLK'S CROSSGATE DISCOUNT DRUGS INC.
Other - Org Name:PMO PHARMACY MGMT DOTHAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:334-699-3900
Mailing Address - Street 1:3119 WESLEY WAY
Mailing Address - Street 2:STE 6
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-2002
Mailing Address - Country:US
Mailing Address - Phone:334-699-3900
Mailing Address - Fax:334-699-3902
Practice Address - Street 1:3119 WESLEY WAY STE 6
Practice Address - Street 2:STE 6
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-2000
Practice Address - Country:US
Practice Address - Phone:334-699-3900
Practice Address - Fax:334-699-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1128183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100003723Medicaid
1995930OtherPK
FL031628800Medicaid
GA794290082AMedicaid
FL031628800Medicaid