Healthcare Provider Details

I. General information

NPI: 1912104415
Provider Name (Legal Business Name): MACON CITY DRUG STORE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3281 JEFFERSON ST
MACON MS
39341-2279
US

IV. Provider business mailing address

PO BOX 424
MACON MS
39341-0424
US

V. Phone/Fax

Practice location:
  • Phone: 662-726-5143
  • Fax: 662-726-5183
Mailing address:
  • Phone: 662-726-5143
  • Fax: 662-726-5183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0012501.1
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BECKY GENE WATT
Title or Position: DME PROVIDER
Credential:
Phone: 662-726-5143