Provider Demographics
NPI:1053408245
Name:ESSCO DISCOUNT DRUG CENTER INC
Entity type:Organization
Organization Name:ESSCO DISCOUNT DRUG CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-746-7423
Mailing Address - Street 1:732 E FIFTEENTH ST
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-2706
Mailing Address - Country:US
Mailing Address - Phone:662-746-7423
Mailing Address - Fax:662-746-8158
Practice Address - Street 1:732 E FIFTEENTH ST
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-2706
Practice Address - Country:US
Practice Address - Phone:662-746-7423
Practice Address - Fax:662-746-8158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X, 3336S0011X
MS014093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0030034Medicaid
2507955OtherNCPDP PROVIDER IDENTIFICATION NUMBER