Provider Demographics
NPI:1184713877
Name:CITY DRUG STORE INC
Entity type:Organization
Organization Name:CITY DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:731-989-7884
Mailing Address - Street 1:PO BOX 224
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-0224
Mailing Address - Country:US
Mailing Address - Phone:731-989-2166
Mailing Address - Fax:731-989-9685
Practice Address - Street 1:226 NORTH AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-1816
Practice Address - Country:US
Practice Address - Phone:731-989-7884
Practice Address - Fax:731-989-2111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN13413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2094496OtherPK
TN1454894Medicaid