Provider Demographics
NPI:1215140967
Name:LEE'S DRUG STORE
Entity type:Organization
Organization Name:LEE'S DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-694-2191
Mailing Address - Street 1:28 LIPSEY
Mailing Address - Street 2:P.O. BOX 819
Mailing Address - City:PRENTISS
Mailing Address - State:MS
Mailing Address - Zip Code:39474-0819
Mailing Address - Country:US
Mailing Address - Phone:601-792-2193
Mailing Address - Fax:601-792-4003
Practice Address - Street 1:404 MAIN AVE.
Practice Address - Street 2:
Practice Address - City:NEWHEBRON
Practice Address - State:MS
Practice Address - Zip Code:39140-0097
Practice Address - Country:US
Practice Address - Phone:601-694-2191
Practice Address - Fax:601-792-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-7347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330702Medicaid
MS00330702Medicaid