=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184713877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY DRUG STORE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 02/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 226 NORTH AVE
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38340-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-989-7884
-----------------------------------------------------
Fax | 731-989-2111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 224
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38340-0224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-989-2166
-----------------------------------------------------
Fax | 731-989-9685
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PIC
-----------------------------------------------------
Name | JENNIFER MORRIS
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 731-989-7884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 1341
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------