Healthcare Provider Details

I. General information

NPI: 1205802980
Provider Name (Legal Business Name): CITY DRUGS OF CRYSTAL SPRINGS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 BO BO DR
CRYSTAL SPRINGS MS
39059-2741
US

IV. Provider business mailing address

113 BO BO DR
CRYSTAL SPRINGS MS
39059-2741
US

V. Phone/Fax

Practice location:
  • Phone: 601-892-4121
  • Fax: 601-892-1598
Mailing address:
  • Phone: 601-892-4121
  • Fax: 601-892-1598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number01756/1.1
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number01756/01.1
License Number StateMS

VIII. Authorized Official

Name: MR. REAGAN L BROWN
Title or Position: PHARMACIST
Credential: RPH
Phone: 601-892-4121