Provider Demographics
NPI:1932138872
Name:POLK'S CROSSGATE DISCOUNT DRUGS INC.
Entity Type:Organization
Organization Name:POLK'S CROSSGATE DISCOUNT DRUGS INC.
Other - Org Name:POLK'S DISCOUNT DRUGS # 4
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:L
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-992-4450
Mailing Address - Street 1:1866 SPILLWAY RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6063
Mailing Address - Country:US
Mailing Address - Phone:601-992-4466
Mailing Address - Fax:601-992-4415
Practice Address - Street 1:1866 SPILLWAY RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6063
Practice Address - Country:US
Practice Address - Phone:601-992-4466
Practice Address - Fax:601-992-4415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS02279183500000X
332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0030406Medicaid
MS01402218Medicaid
MS0030406Medicaid