Provider Demographics
NPI:1174871057
Name:DEER CREEK PHARMACY LLC
Entity type:Organization
Organization Name:DEER CREEK PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-873-7135
Mailing Address - Street 1:56 S FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLING FORK
Mailing Address - State:MS
Mailing Address - Zip Code:39159-5147
Mailing Address - Country:US
Mailing Address - Phone:662-873-6006
Mailing Address - Fax:
Practice Address - Street 1:56 S FOURTH ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5147
Practice Address - Country:US
Practice Address - Phone:662-873-6006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
MS114823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136470OtherPK