Provider Demographics
NPI:1417148396
Name:SERVICE DRUG STORE INC
Entity Type:Organization
Organization Name:SERVICE DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:M
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:850-263-3257
Mailing Address - Street 1:P.O. BOX 216
Mailing Address - Street 2:
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440
Mailing Address - Country:US
Mailing Address - Phone:850-263-3257
Mailing Address - Fax:850-263-3220
Practice Address - Street 1:5341 BROWN ST.
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440
Practice Address - Country:US
Practice Address - Phone:850-263-3257
Practice Address - Fax:850-263-3220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
FLPH258483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100454901Medicaid
FL100454900Medicaid
FL1039153OtherNABP
FL1039153OtherNABP