Provider Demographics
NPI:1912104415
Name:MACON CITY DRUG STORE, INC.
Entity type:Organization
Organization Name:MACON CITY DRUG STORE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DME PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:WATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-726-5143
Mailing Address - Street 1:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MS
Mailing Address - Zip Code:39341-0424
Mailing Address - Country:US
Mailing Address - Phone:662-726-5143
Mailing Address - Fax:662-726-5183
Practice Address - Street 1:3281 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341-2279
Practice Address - Country:US
Practice Address - Phone:662-726-5143
Practice Address - Fax:662-726-5183
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACON CITY DRUG STORE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-28
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
MS0012501.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440507OtherMEDICAID DME #
MS2505367OtherNABP #
MS00039888Medicaid
MS0771340001Medicare NSC