Provider Demographics
NPI:1508936683
Name:BRENTS DRUGS INC
Entity Type:Organization
Organization Name:BRENTS DRUGS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CALVERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-366-1012
Mailing Address - Street 1:655 DULING AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4008
Mailing Address - Country:US
Mailing Address - Phone:601-366-1012
Mailing Address - Fax:601-366-0263
Practice Address - Street 1:655 DULING AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4008
Practice Address - Country:US
Practice Address - Phone:601-366-3428
Practice Address - Fax:601-366-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00743011333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2504555OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS0035394Medicaid
MS0175390001Medicare NSC