Provider Demographics
NPI:1407946320
Name:GREGORY T LEE
Entity Type:Organization
Organization Name:GREGORY T LEE
Other - Org Name:PALACE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-792-4959
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474-0819
Mailing Address - Country:US
Mailing Address - Phone:601-792-4959
Mailing Address - Fax:
Practice Address - Street 1:2234 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-0819
Practice Address - Country:US
Practice Address - Phone:601-792-4959
Practice Address - Fax:601-792-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS04377/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2043400OtherPK
MS00330448Medicaid