Provider Demographics
NPI:1306097902
Name:POLK'S CROSSGATE DISCOUNT DRUGS INC.
Entity type:Organization
Organization Name:POLK'S CROSSGATE DISCOUNT DRUGS INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-940-0668
Mailing Address - Street 1:1031 STAR RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-9010
Mailing Address - Country:US
Mailing Address - Phone:601-825-4507
Mailing Address - Fax:601-825-4524
Practice Address - Street 1:1031 STAR RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-9010
Practice Address - Country:US
Practice Address - Phone:601-825-4507
Practice Address - Fax:601-825-4524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS07891/01.23336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07308025Medicaid
2117242OtherPK