Provider Demographics
NPI:1154354314
Name:SULLIVAN'S DISCOUNT DRUGS INC.
Entity type:Organization
Organization Name:SULLIVAN'S DISCOUNT DRUGS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-289-3234
Mailing Address - Street 1:109 NORTHSIDE SHOPPING CENTER
Mailing Address - Street 2:HWY 12 W
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090
Mailing Address - Country:US
Mailing Address - Phone:662-289-3234
Mailing Address - Fax:662-289-3030
Practice Address - Street 1:109 NORTHSIDE SHOPPING CENTER
Practice Address - Street 2:HWY 12 W
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090
Practice Address - Country:US
Practice Address - Phone:662-289-3234
Practice Address - Fax:662-289-3030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00233333600000X, 3336L0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00034452Medicaid
MS2505026OtherNCPDP #
MS870001250Medicare ID - Type Unspecified