Provider Demographics
NPI:1558455907
Name:CITY DRUG STORE,INC
Entity Type:Organization
Organization Name:CITY DRUG STORE,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HASSETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-827-5561
Mailing Address - Street 1:P. O. BOX 426
Mailing Address - Street 2:
Mailing Address - City:HOLLANDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38748-0426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:662-827-5561
Practice Address - Street 1:100 W. WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOLLANDALE
Practice Address - State:MS
Practice Address - Zip Code:38748-0426
Practice Address - Country:US
Practice Address - Phone:662-827-5561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00115/01.1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2504290OtherNABP
MS00030902Medicaid