Provider Demographics
NPI:1194868539
Name:MOUNT VERNON DRUG COMPANY
Entity type:Organization
Organization Name:MOUNT VERNON DRUG COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER REGISTERED PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:DARRELL
Authorized Official - Last Name:SAMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-583-2216
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:421 S RAILROAD AVENUE
Mailing Address - City:MOUNT VERNON
Mailing Address - State:GA
Mailing Address - Zip Code:30445-0195
Mailing Address - Country:US
Mailing Address - Phone:912-583-2216
Mailing Address - Fax:912-583-2217
Practice Address - Street 1:421 S RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:GA
Practice Address - Zip Code:30445-0195
Practice Address - Country:US
Practice Address - Phone:912-583-2216
Practice Address - Fax:912-583-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005037183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000032425AMedicaid
GA000032425AMedicaid