Healthcare Provider Details

I. General information

NPI: 1225191877
Provider Name (Legal Business Name): DECATUR DRUGS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 W BROAD ST
DECATUR MS
39327-8959
US

IV. Provider business mailing address

PO BOX 98
DECATUR MS
39327-0098
US

V. Phone/Fax

Practice location:
  • Phone: 601-635-2646
  • Fax: 601-635-4039
Mailing address:
  • Phone: 601-635-2646
  • Fax: 601-635-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-6485
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHARLES AUSTIN BOGGAN
Title or Position: OWNER
Credential: RPH
Phone: 601-635-2646