MEDICARE: FAMILY DRUG CENTER

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	3336C0003X	Community/Retail Pharmacy	0201002977	VA

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	4826662	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1033207469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY DRUG CENTER

Provider Business Mailing Address
First Line	:	PO BOX 129
Second Line	:
City	:	DAVENPORT
State	:	VA
Zip	:	24239-0129
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	STATE ROUTE 80
Second Line	:
City	:	DAVENPORT
State	:	VA
Zip	:	24239-0129
Country	:	US
Telephone Number	:	276-859-0409
Fax Number	:	276-859-0329

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLDEEN BAGWELL
Credential	:
Telephone Number	:	276-935-8797

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	06/26/2008

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Directions to “FAMILY DRUG CENTER ” Practice Location

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