Provider Demographics
NPI:1629008859
Name:POLKS CROSSGATES DISCOUNT DRUGS, INC.
Entity Type:Organization
Organization Name:POLKS CROSSGATES DISCOUNT DRUGS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-825-8660
Mailing Address - Street 1:335 CROSSGATES BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2602
Mailing Address - Country:US
Mailing Address - Phone:601-825-8660
Mailing Address - Fax:601-825-6983
Practice Address - Street 1:335 CROSSGATES BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2602
Practice Address - Country:US
Practice Address - Phone:601-825-8660
Practice Address - Fax:601-825-6983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01619/01.2183500000X
MS01619- 01.23336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00095346Medicaid
MS00045115Medicaid
MS0169480001Medicare NSC