Provider Demographics
NPI:1013925122
Name:POLK'S CROSSGATES DISCOUNT DRUGS INC.
Entity Type:Organization
Organization Name:POLK'S CROSSGATES DISCOUNT DRUGS INC.
Other - Org Name:PMO PHARMACY MANAGENMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:PARKS
Authorized Official - Last Name:JONES
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:601-420-5150
Mailing Address - Street 1:319 CROSSPARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39208
Mailing Address - Country:US
Mailing Address - Phone:601-420-5150
Mailing Address - Fax:601-420-5502
Practice Address - Street 1:319 CROSS PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39208-8905
Practice Address - Country:US
Practice Address - Phone:601-420-5150
Practice Address - Fax:601-420-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04134183700000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330604Medicaid
MS00440744Medicaid
LA1264474Medicaid
MS00330604Medicaid