Provider Demographics
NPI:1417965740
Name:KING AND MCNULTY, LLC
Entity Type:Organization
Organization Name:KING AND MCNULTY, LLC
Other - Org Name:DIXON DISCOUNT PHARMACY, GLOSTER DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:CRT
Authorized Official - Phone:601-849-4112
Mailing Address - Street 1:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-1100
Mailing Address - Country:US
Mailing Address - Phone:601-849-6440
Mailing Address - Fax:601-849-7557
Practice Address - Street 1:434 B SOUTH CAPTAIN GLOSTER DRIVE
Practice Address - Street 2:
Practice Address - City:GLOSTER
Practice Address - State:MS
Practice Address - Zip Code:39638
Practice Address - Country:US
Practice Address - Phone:601-225-7907
Practice Address - Fax:601-225-7906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06673/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00639091Medicaid
2586228OtherNCPDP
BD9388794OtherDEA
MS5538300001Medicare ID - Type Unspecified