MEDICARE: SOUTHERN DISCOUNT DRUGS OF CHARLESTON 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	332B00000X	Durable Medical Equipment & Medical Supplies	1022	AL
2	332B00000X	Durable Medical Equipment & Medical Supplies	8226997-1714	UT
3	332B00000X	Durable Medical Equipment & Medical Supplies	056014	AR
4	332B00000X	Durable Medical Equipment & Medical Supplies	DME18182	ID
5	332B00000X	Durable Medical Equipment & Medical Supplies	NPC-0003778	OR
6	332B00000X	Durable Medical Equipment & Medical Supplies	MP00957	NV
7	332B00000X	Durable Medical Equipment & Medical Supplies	P013728	AZ
8	332B00000X	Durable Medical Equipment & Medical Supplies	06473/11.1	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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	4057054	OTHER	TN	BC TN
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104800440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN DISCOUNT DRUGS OF CHARLESTON INC

Provider Business Mailing Address
First Line	:	1068 FACTORY DR
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-6620
Country	:	US
Telephone Number	:	662-647-6601
Fax Number	:	662-647-2411

Provider Business Practice Location Address
First Line	:	1068 FACTORY DR
Second Line	:
City	:	CHARLESTON
State	:	MS
Zip	:	38921-6620
Country	:	US
Telephone Number	:	662-647-6601
Fax Number	:	662-647-2411

Authorized Official
Title or Position	:	PHARMACIST
Name	:	MR. ROBERT SALMON
Credential	:	RPH
Telephone Number	:	662-647-2591

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	07/11/2019

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