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General NPI Number Information
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NPI Number | 1174871057
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Entity Type | Organization
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Legal Business Name | DEER CREEK PHARMACY LLC
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Dates
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Enumeration Date | 08/27/2012
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Last Update Date | 05/09/2016
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Provider Practice Location Address
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Address Line | 56 S FOURTH ST
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City | ROLLING FORK
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State | MS
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Zip | 39159-5147
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Country | US
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Telephone | 662-873-6006
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Fax |
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Provider Business Mailing Address
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Address Line | 56 S FOURTH ST
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City | ROLLING FORK
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State | MS
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Zip | 39159-5147
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Country | US
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Telephone | 662-873-6006
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHARLIE DARDEN
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Credential |
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Telephone | 662-873-7135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 11482
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License Number State | MS
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