MEDICARE: WOODS DRUG STORE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	00528	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2502727	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1003805862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODS DRUG STORE INC

Provider Business Mailing Address
First Line	:	315 W MAIN ST
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-2232
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 W MAIN ST
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-2232
Country	:	US
Telephone Number	:	662-647-5541
Fax Number	:	662-647-5546

Authorized Official
Title or Position	:	CO OWNER PHARMACIST
Name	:	VICTOR BAILEY
Credential	:	RPH
Telephone Number	:	662-647-5541

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	12/03/2007

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