Provider Demographics
NPI:1447362223
Name:MALCOLMS DRUG STORE INC
Entity type:Organization
Organization Name:MALCOLMS DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RPL
Authorized Official - Phone:912-384-1898
Mailing Address - Street 1:250 SOUTH PETERSON AVE
Mailing Address - Street 2:MALCOLMS DRUG STORE INC
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-5237
Mailing Address - Country:US
Mailing Address - Phone:912-384-1989
Mailing Address - Fax:912-383-7109
Practice Address - Street 1:250 SOUTH PETERSON AVE
Practice Address - Street 2:MALCOLMS DRUG STORE INC
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-5237
Practice Address - Country:US
Practice Address - Phone:912-384-1989
Practice Address - Fax:912-383-7109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE007080333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1109277OtherMEMBER HEALTH MHRX