Provider Demographics
NPI:1639254923
Name:COMMUNITY DISCOUNT PHARMACY INC
Entity Type:Organization
Organization Name:COMMUNITY DISCOUNT PHARMACY INC
Other - Org Name:COMMUNITY DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:VINES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-562-5268
Mailing Address - Street 1:305 NORFLEET DR
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2205
Mailing Address - Country:US
Mailing Address - Phone:662-562-5268
Mailing Address - Fax:662-562-6136
Practice Address - Street 1:305 NORFLEET DR
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2205
Practice Address - Country:US
Practice Address - Phone:662-562-5268
Practice Address - Fax:662-562-6136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS012820113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2510902OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MS00095117Medicaid