Provider Demographics
NPI:1124169057
Name:METRO PHARMACY INC
Entity type:Organization
Organization Name:METRO PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT. SECRETARY TREASURE
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:601-346-5567
Mailing Address - Street 1:1815 HOSPITAL DR
Mailing Address - Street 2:SUITE 118
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3425
Mailing Address - Country:US
Mailing Address - Phone:601-346-5567
Mailing Address - Fax:601-346-7371
Practice Address - Street 1:1815 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3425
Practice Address - Country:US
Practice Address - Phone:601-346-5567
Practice Address - Fax:601-346-7371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS02268 01.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2517021OtherNABP
MS00030365Medicaid