Provider Demographics
NPI:1952525081
Name:ROYSTON DRUG STORE, INC
Entity Type:Organization
Organization Name:ROYSTON DRUG STORE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:B
Authorized Official - Last Name:PHILLIPS-MALCOM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:706-245-7223
Mailing Address - Street 1:26 FRANKLIN SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-4109
Mailing Address - Country:US
Mailing Address - Phone:709-245-7223
Mailing Address - Fax:706-245-6727
Practice Address - Street 1:26 FRANKLIN SPRINGS ST
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-4109
Practice Address - Country:US
Practice Address - Phone:709-245-7223
Practice Address - Fax:706-245-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE004096183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00035351AMedicaid