Provider Demographics
NPI:1467532663
Name:CITY DRUG STORE OF HAZLEHURST, INC.
Entity Type:Organization
Organization Name:CITY DRUG STORE OF HAZLEHURST, INC.
Other - Org Name:ROSE'S SUPER DISCOUNT DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:601-894-1222
Mailing Address - Street 1:218 CALDWELL DR
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-2712
Mailing Address - Country:US
Mailing Address - Phone:601-894-1222
Mailing Address - Fax:601-894-1522
Practice Address - Street 1:218 CALDWELL DR
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2712
Practice Address - Country:US
Practice Address - Phone:601-894-1222
Practice Address - Fax:601-894-1522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS002093251K00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030881Medicaid