Provider Demographics
NPI:1104800440
Name:SOUTHERN DISCOUNT DRUGS OF CHARLESTON INC
Entity type:Organization
Organization Name:SOUTHERN DISCOUNT DRUGS OF CHARLESTON INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SALMON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-647-2591
Mailing Address - Street 1:1068 FACTORY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:MS
Mailing Address - Zip Code:38921-6620
Mailing Address - Country:US
Mailing Address - Phone:662-647-6601
Mailing Address - Fax:662-647-2411
Practice Address - Street 1:1068 FACTORY DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MS
Practice Address - Zip Code:38921-6620
Practice Address - Country:US
Practice Address - Phone:662-647-6601
Practice Address - Fax:662-647-2411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1022332B00000X
UT8226997-1714332B00000X
AR056014332B00000X
IDDME18182332B00000X
ORNPC-0003778332B00000X
NVMP00957332B00000X
AZP013728332B00000X
MS06473/11.1332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175578701 175578702Medicaid
LA1757861Medicaid
MS00040385Medicaid
TN4057054OtherBC TN
AK152800716Medicaid
MS=========OtherTAX ID NUMBER
LA1757861Medicaid