Provider Demographics
NPI:1649209305
Name:NORTHLAUREL DISCOUNT DRUGS, INC.
Entity Type:Organization
Organization Name:NORTHLAUREL DISCOUNT DRUGS, INC.
Other - Org Name:QUINN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:HICKS, III
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-428-0688
Mailing Address - Street 1:3160 AUDUBON DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-1926
Mailing Address - Country:US
Mailing Address - Phone:601-428-0688
Mailing Address - Fax:601-428-0689
Practice Address - Street 1:3160 AUDUBON DR
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-1926
Practice Address - Country:US
Practice Address - Phone:601-428-0688
Practice Address - Fax:601-428-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01101/01.1332BP3500X, 3336C0003X, 332BP3500X
MS01101/013336C0004X
MS1101/013336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030428Medicaid
MS00030428Medicaid