Provider Demographics
NPI:1851459812
Name:SPENCER'S DRUG
Entity Type:Organization
Organization Name:SPENCER'S DRUG
Other - Org Name:SPENCER'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TREADWELL
Authorized Official - Middle Name:HARVEY
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:R PH
Authorized Official - Phone:662-756-4650
Mailing Address - Street 1:107 W FLOYCE ST
Mailing Address - Street 2:
Mailing Address - City:RULEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38771-3923
Mailing Address - Country:US
Mailing Address - Phone:662-756-4650
Mailing Address - Fax:662-756-2533
Practice Address - Street 1:107 W FLOYCE ST
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-3923
Practice Address - Country:US
Practice Address - Phone:662-756-4650
Practice Address - Fax:662-756-2533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-35133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00034355Medicaid
MS00034355Medicaid