Provider Demographics
NPI:1588793228
Name:CORNER DRUG STORE OF MAGNOLIA INC
Entity type:Organization
Organization Name:CORNER DRUG STORE OF MAGNOLIA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIMES
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:601-783-2321
Mailing Address - Street 1:101 W RAILROAD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:MS
Mailing Address - Zip Code:39652-2835
Mailing Address - Country:US
Mailing Address - Phone:601-783-2321
Mailing Address - Fax:601-783-2497
Practice Address - Street 1:101 W RAILROAD AVE N
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:MS
Practice Address - Zip Code:39652-2835
Practice Address - Country:US
Practice Address - Phone:601-783-2321
Practice Address - Fax:601-783-2497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
MS00146011332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440568Medicaid
MS00440568Medicaid