Healthcare Provider Details

I. General information

NPI: 1932104650
Provider Name (Legal Business Name): TYSON DRUGS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 01/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 J M ASH DR
HOLLY SPRINGS MS
38635-3238
US

IV. Provider business mailing address

530 J M ASH DR
HOLLY SPRINGS MS
38635-3238
US

V. Phone/Fax

Practice location:
  • Phone: 662-252-1011
  • Fax: 662-252-1189
Mailing address:
  • Phone: 662-252-1011
  • Fax: 662-252-1189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberF04232
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0432/01.1
License Number StateMS

VIII. Authorized Official

Name: MR. ROBERT HUDSON LOMENICK
Title or Position: OWNER/ PHARMACIST
Credential: RPH
Phone: 662-252-1011