Provider Demographics
NPI:1639124183
Name:LIBERTY DRUG STORE, INC.
Entity Type:Organization
Organization Name:LIBERTY DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:BLALOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-657-8051
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MS
Mailing Address - Zip Code:39645-0217
Mailing Address - Country:US
Mailing Address - Phone:601-657-8051
Mailing Address - Fax:601-657-8049
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MS
Practice Address - Zip Code:39645
Practice Address - Country:US
Practice Address - Phone:601-657-8051
Practice Address - Fax:601-657-8049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST08879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330466Medicaid
MS00440833Medicaid
MS00330466Medicaid