Provider Demographics
NPI:1952316721
Name:CITY DRUG STORE
Entity Type:Organization
Organization Name:CITY DRUG STORE
Other - Org Name:CITY DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER RPH
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:912-265-7630
Mailing Address - Street 1:1402 NEWCASTLE ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-7018
Mailing Address - Country:US
Mailing Address - Phone:912-265-7630
Mailing Address - Fax:912-262-1123
Practice Address - Street 1:1402 NEWCASTLE ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-7018
Practice Address - Country:US
Practice Address - Phone:912-265-7630
Practice Address - Fax:912-262-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0055633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00192585AMedicaid
GA00192585AMedicaid
GA73BBBDGMedicare PIN