Provider Demographics
NPI:1699872523
Name:LOCKE DRUG STORE INC
Entity type:Organization
Organization Name:LOCKE DRUG STORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-837-7177
Mailing Address - Street 1:410 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38663-2112
Mailing Address - Country:US
Mailing Address - Phone:662-837-7177
Mailing Address - Fax:662-837-7719
Practice Address - Street 1:410 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:MS
Practice Address - Zip Code:38663-2112
Practice Address - Country:US
Practice Address - Phone:662-837-7177
Practice Address - Fax:662-837-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS005040113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030030Medicaid
2506941OtherNCPDP PROVIDER IDENTIFICATION NUMBER
2506941OtherNCPDP PROVIDER IDENTIFICATION NUMBER