Provider Demographics
NPI:1033207469
Name:FAMILY DRUG CENTER
Entity Type:Organization
Organization Name:FAMILY DRUG CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLDEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-935-8797
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:VA
Mailing Address - Zip Code:24239-0129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:STATE ROUTE 80
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:VA
Practice Address - Zip Code:24239-0129
Practice Address - Country:US
Practice Address - Phone:276-859-0409
Practice Address - Fax:276-859-0329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010029773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010187303Medicaid
4826662OtherOTHER ID NUMBER