Provider Demographics
NPI:1386912483
Name:POLK'S CROSSGATES DISCOUNT DRUGS INC.
Entity type:Organization
Organization Name:POLK'S CROSSGATES DISCOUNT DRUGS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FLYNT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:228-207-0505
Mailing Address - Street 1:1845 POPPS FERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532
Mailing Address - Country:US
Mailing Address - Phone:228-207-0505
Mailing Address - Fax:877-567-2135
Practice Address - Street 1:1845 POPPS FERRY ROAD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532
Practice Address - Country:US
Practice Address - Phone:228-207-0505
Practice Address - Fax:877-567-2135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POLK'S CROSSGATES DISCOUNT DRUGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-05
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF097433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0169480009Medicare NSC