Provider Demographics
NPI:1841370137
Name:HAGGARD DRUG STORE INC.
Entity type:Organization
Organization Name:HAGGARD DRUG STORE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:CAREY
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-624-8361
Mailing Address - Street 1:301 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-4307
Mailing Address - Country:US
Mailing Address - Phone:662-624-8361
Mailing Address - Fax:662-624-5678
Practice Address - Street 1:301 3RD ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-4307
Practice Address - Country:US
Practice Address - Phone:662-624-8361
Practice Address - Fax:662-624-5678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00411/01.1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00032212Medicaid