Healthcare Provider Details

I. General information

NPI: 1013925122
Provider Name (Legal Business Name): POLK'S CROSSGATES DISCOUNT DRUGS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 CROSS PARK DR
JACKSON MS
39208-8905
US

IV. Provider business mailing address

319 CROSSPARK DR
JACKSON MS
39208
US

V. Phone/Fax

Practice location:
  • Phone: 601-420-5150
  • Fax: 601-420-5502
Mailing address:
  • Phone: 601-420-5150
  • Fax: 601-420-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number04134
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. KENDALL PARKS JONES JR.
Title or Position: MANAGER
Credential:
Phone: 601-420-5150