Provider Demographics
NPI:1558400549
Name:SULLIVAN'S DISCOUNT DRUGS, INC
Entity Type:Organization
Organization Name:SULLIVAN'S DISCOUNT DRUGS, INC
Other - Org Name:SULLIVAN'S DISCOUNT DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-289-3234
Mailing Address - Street 1:109 NORTHSIDE CTR
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3254
Mailing Address - Country:US
Mailing Address - Phone:662-289-3234
Mailing Address - Fax:662-289-3030
Practice Address - Street 1:109 NORTHSIDE CTR
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3254
Practice Address - Country:US
Practice Address - Phone:662-289-3234
Practice Address - Fax:662-289-3030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0023301.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440359Medicaid
MS1215010001Medicare NSC