Provider Demographics
NPI:1518997410
Name:POLK'S CROSSGATE DISCOUNT DRUGS INC.
Entity Type:Organization
Organization Name:POLK'S CROSSGATE DISCOUNT DRUGS INC.
Other - Org Name:POLK'S DISCOUNT DRUGS #5
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SKELTON
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:601-932-8609
Mailing Address - Street 1:PO BOX 180038
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-0038
Mailing Address - Country:US
Mailing Address - Phone:601-932-8609
Mailing Address - Fax:601-933-0024
Practice Address - Street 1:1201 HIGHWAY 49 S
Practice Address - Street 2:STE 2
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-9425
Practice Address - Country:US
Practice Address - Phone:601-932-8609
Practice Address - Fax:601-933-0024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MSF023843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330041Medicaid
2045389OtherPK
0169480003Medicare NSC