Provider Demographics
NPI:1639135908
Name:RUSSELLS MR DISCOUNT DRUGS
Entity Type:Organization
Organization Name:RUSSELLS MR DISCOUNT DRUGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-834-1154
Mailing Address - Street 1:334 DEPOT STREET
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095-3607
Mailing Address - Country:US
Mailing Address - Phone:662-834-1154
Mailing Address - Fax:662-834-0681
Practice Address - Street 1:334 DEPOT STREET
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-3607
Practice Address - Country:US
Practice Address - Phone:662-834-1154
Practice Address - Fax:662-834-0681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR068863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330451Medicaid
MS00330451Medicaid