Provider Demographics
NPI:1508413592
Name:ROLLING FORK DRUG CO
Entity Type:Organization
Organization Name:ROLLING FORK DRUG CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:M
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-207-0616
Mailing Address - Street 1:903 HIGHWAY 82 E BLDG G
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-2325
Mailing Address - Country:US
Mailing Address - Phone:662-887-4135
Mailing Address - Fax:662-887-9703
Practice Address - Street 1:20917 HIGHWAY 61
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5027
Practice Address - Country:US
Practice Address - Phone:662-873-4723
Practice Address - Fax:662-873-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-23
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy