Provider Demographics
NPI:1962599159
Name:LONG BEACH DRUGS LLC
Entity type:Organization
Organization Name:LONG BEACH DRUGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARM
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-822-9868
Mailing Address - Street 1:5107 BEATLINE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-3871
Mailing Address - Country:US
Mailing Address - Phone:228-822-9868
Mailing Address - Fax:228-822-2312
Practice Address - Street 1:5107 BEATLINE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-3871
Practice Address - Country:US
Practice Address - Phone:228-822-9868
Practice Address - Fax:228-822-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MS062703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2521854OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MS04689397Medicaid