Provider Demographics
NPI:1770657793
Name:SHELBY DRUG CO INC HWY 61 SOUTH
Entity Type:Organization
Organization Name:SHELBY DRUG CO INC HWY 61 SOUTH
Other - Org Name:QUITMAN DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARM
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-326-3505
Mailing Address - Street 1:1026 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MARKS
Mailing Address - State:MS
Mailing Address - Zip Code:38646-1832
Mailing Address - Country:US
Mailing Address - Phone:662-326-3505
Mailing Address - Fax:662-326-6916
Practice Address - Street 1:1026 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-1832
Practice Address - Country:US
Practice Address - Phone:662-326-3505
Practice Address - Fax:662-326-6916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MS01675/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00090345Medicaid
2044766OtherPK