Provider Demographics
NPI:1639211121
Name:MACON CITY DRUG STORE, INC.
Entity Type:Organization
Organization Name:MACON CITY DRUG STORE, INC.
Other - Org Name:BROOKSVILLE DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:BELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:662-738-5041
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39739-0312
Mailing Address - Country:US
Mailing Address - Phone:662-738-5041
Mailing Address - Fax:662-738-5043
Practice Address - Street 1:1556 N OLIVER ST
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39739-4003
Practice Address - Country:US
Practice Address - Phone:662-738-5041
Practice Address - Fax:662-738-5043
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACON CITY DRUG STORE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-13
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS061583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06689871Medicaid