Provider Demographics
NPI:1194889568
Name:HOLLIS DISCOUNT PHARMACY, INC
Entity type:Organization
Organization Name:HOLLIS DISCOUNT PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-837-7323
Mailing Address - Street 1:1008 CITY AVE N
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-1413
Mailing Address - Country:US
Mailing Address - Phone:662-837-4774
Mailing Address - Fax:
Practice Address - Street 1:1008 CITY AVE N
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-1413
Practice Address - Country:US
Practice Address - Phone:662-837-4774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2023-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS1326333600000X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00095087Medicaid
MS1033450001Medicare NSC