Provider Demographics
NPI:1548395825
Name:SHELBY DRUG CO INC HWY 61 SOUTH
Entity Type:Organization
Organization Name:SHELBY DRUG CO INC HWY 61 SOUTH
Other - Org Name:SHELBY DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-624-2526
Mailing Address - Street 1:1211 BROADWAY HWY 61 SO
Mailing Address - Street 2:PO BOX 1105
Mailing Address - City:SHELBY
Mailing Address - State:MS
Mailing Address - Zip Code:38774
Mailing Address - Country:US
Mailing Address - Phone:662-398-7487
Mailing Address - Fax:662-398-7109
Practice Address - Street 1:1211 BROADWAY HWY 61 SO
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MS
Practice Address - Zip Code:38774
Practice Address - Country:US
Practice Address - Phone:662-398-7487
Practice Address - Fax:662-398-7109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00798/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2507119OtherNCPDP PROVIDER IDENTIFICATION NUMBER