Provider Demographics
NPI:1972693927
Name:MOSBYS DRUG STORE
Entity Type:Organization
Organization Name:MOSBYS DRUG STORE
Other - Org Name:MOSBY'S DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:ACCOUNTANT
Authorized Official - Phone:601-859-3939
Mailing Address - Street 1:195 EAST PEACE STREET
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046
Mailing Address - Country:US
Mailing Address - Phone:601-859-3939
Mailing Address - Fax:601-855-2133
Practice Address - Street 1:1301 E PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4937
Practice Address - Country:US
Practice Address - Phone:601-859-4212
Practice Address - Fax:601-859-4260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
MS00235/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157850OtherPK
MS000033316Medicaid
MS00033316Medicaid