Basic Information
| Provider Information | |||||||||
| NPI: | 1043372915 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MALCOLMS DRUG STORE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 PETERSON AVE S | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315335237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123841898 | ||||||||
| FaxNumber: | 9123837109 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 PETERSON AVE S | ||||||||
| Address2: | |||||||||
| City: | DOUGLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315335237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123841898 | ||||||||
| FaxNumber: | 9123837109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9123841898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | PROF. | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PHRE007181 | GA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 00031237A | 05 | GA | MEDICAID | 1109277 | 01 | GA | NABP NUMBER | OTHER |