Provider Demographics
NPI:1457429144
Name:MCCONAGHY DRUG STORE, INC
Entity Type:Organization
Organization Name:MCCONAGHY DRUG STORE, INC
Other - Org Name:MCINTOSH DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DME DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-944-8227
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:MC INTOSH
Mailing Address - State:AL
Mailing Address - Zip Code:36553-0247
Mailing Address - Country:US
Mailing Address - Phone:251-944-8227
Mailing Address - Fax:251-944-8226
Practice Address - Street 1:61 RIVER RD
Practice Address - Street 2:
Practice Address - City:MCINTOSH
Practice Address - State:AL
Practice Address - Zip Code:36553
Practice Address - Country:US
Practice Address - Phone:251-944-8227
Practice Address - Fax:251-944-8226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL106354332B00000X, 332BX2000X
332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000054843Medicaid