Healthcare Provider Details

I. General information

NPI: 1518997410
Provider Name (Legal Business Name): POLK'S CROSSGATE DISCOUNT DRUGS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 HIGHWAY 49 S STE 2
RICHLAND MS
39218-9425
US

IV. Provider business mailing address

PO BOX 180038
RICHLAND MS
39218-0038
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-8609
  • Fax: 601-933-0024
Mailing address:
  • Phone: 601-932-8609
  • Fax: 601-933-0024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberF02384
License Number StateMS

VIII. Authorized Official

Name: RONALD SKELTON
Title or Position: MANAGER
Credential: B.S. PHARMACY
Phone: 601-932-8609