Healthcare Provider Details

I. General information

NPI: 1497541775
Provider Name (Legal Business Name): STATE LINE DRUGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 MAIN ST
STATE LINE MS
39362-9600
US

IV. Provider business mailing address

PO BOX 159
STATE LINE MS
39362-0159
US

V. Phone/Fax

Practice location:
  • Phone: 601-848-7866
  • Fax:
Mailing address:
  • Phone: 601-848-7866
  • Fax: 601-848-7346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JAMES CHARLES SNYDER
Title or Position: OWNER
Credential: R,PH
Phone: 601-394-8264