Provider Demographics
NPI:1508961947
Name:POLKS DISCOUNT DRUGS #2
Entity Type:Organization
Organization Name:POLKS DISCOUNT DRUGS #2
Other - Org Name:POLKS CROSSGATES DISCOUNT DRUGS INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACIST/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WILLOUGHBY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-845-8610
Mailing Address - Street 1:101 49 PL
Mailing Address - Street 2:P.O. BOX 266
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-8080
Mailing Address - Country:US
Mailing Address - Phone:601-845-8610
Mailing Address - Fax:601-845-8650
Practice Address - Street 1:101 49 PLACE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073
Practice Address - Country:US
Practice Address - Phone:601-845-8610
Practice Address - Fax:601-845-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS020143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030485Medicaid
MS00040389Medicaid
MS0169480002Medicare NSC