Provider Demographics
NPI:1568480507
Name:LEE DRUG STORE, INC.
Entity type:Organization
Organization Name:LEE DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/TREASURER - LEE DRUG STOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:RAWLS
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MSC, AL PHARM
Authorized Official - Phone:251-947-7378
Mailing Address - Street 1:PO BOX 929
Mailing Address - Street 2:18530 FLORIDA ST
Mailing Address - City:ROBERTSDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36567-0929
Mailing Address - Country:US
Mailing Address - Phone:251-947-7378
Mailing Address - Fax:251-947-7394
Practice Address - Street 1:18530 FLORIDA STREET
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567
Practice Address - Country:US
Practice Address - Phone:251-947-7378
Practice Address - Fax:251-947-7394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL106040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0103008OtherNACDP
AL100003552Medicaid