Provider Demographics
NPI:1932104650
Name:TYSON DRUGS INC
Entity Type:Organization
Organization Name:TYSON DRUGS INC
Other - Org Name:TYSONS MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HUDSON
Authorized Official - Last Name:LOMENICK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-252-1011
Mailing Address - Street 1:530 J M ASH DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-3238
Mailing Address - Country:US
Mailing Address - Phone:662-252-1011
Mailing Address - Fax:662-252-1189
Practice Address - Street 1:530 J M ASH DR
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-3238
Practice Address - Country:US
Practice Address - Phone:662-252-1011
Practice Address - Fax:662-252-1189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TYSON DRUGS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-17
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MS0432/01.1333600000X
MSF042323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2519354OtherNCPDP
MS00330425Medicaid
MS00330425Medicaid