Provider Demographics
NPI:1255341079
Name:POLKS CROSSGATES DISCOUNT DRUGS INC 6
Entity type:Organization
Organization Name:POLKS CROSSGATES DISCOUNT DRUGS INC 6
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:601-371-8662
Mailing Address - Street 1:7264 SIWELL ROAD
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272
Mailing Address - Country:US
Mailing Address - Phone:601-371-8662
Mailing Address - Fax:601-371-8671
Practice Address - Street 1:7264 SIWELL ROAD
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272
Practice Address - Country:US
Practice Address - Phone:601-371-8662
Practice Address - Fax:601-371-8671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS033283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330223Medicaid