Provider Demographics
NPI:1285715037
Name:BACK BAY DRUGS LLC
Entity type:Organization
Organization Name:BACK BAY DRUGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:AYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:228-396-2257
Mailing Address - Street 1:10437 LAMEY BRIDGE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-2709
Mailing Address - Country:US
Mailing Address - Phone:228-396-2228
Mailing Address - Fax:228-396-2257
Practice Address - Street 1:10437 LAMEY BRIDGE RD
Practice Address - Street 2:SUITE A
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2709
Practice Address - Country:US
Practice Address - Phone:228-396-2228
Practice Address - Fax:228-396-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0330637Medicaid