Provider Demographics
NPI:1205802980
Name:CITY DRUGS OF CRYSTAL SPRINGS, INC.
Entity type:Organization
Organization Name:CITY DRUGS OF CRYSTAL SPRINGS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:REAGAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-892-4121
Mailing Address - Street 1:113 BO BO DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-2741
Mailing Address - Country:US
Mailing Address - Phone:601-892-4121
Mailing Address - Fax:601-892-1598
Practice Address - Street 1:113 BO BO DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2741
Practice Address - Country:US
Practice Address - Phone:601-892-4121
Practice Address - Fax:601-892-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS01756/1.13336L0003X
MS01756/01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030165Medicaid
MS2501624OtherNCPDP NUMBER
MS0471390001Medicare NSC