Provider Demographics
NPI:1225191877
Name:DECATUR DRUGS INC
Entity Type:Organization
Organization Name:DECATUR DRUGS INC
Other - Org Name:WHEELER DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:BOGGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:601-635-2646
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MS
Mailing Address - Zip Code:39327-0098
Mailing Address - Country:US
Mailing Address - Phone:601-635-2646
Mailing Address - Fax:601-635-4039
Practice Address - Street 1:95 W BROAD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:MS
Practice Address - Zip Code:39327-8959
Practice Address - Country:US
Practice Address - Phone:601-635-2646
Practice Address - Fax:601-635-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-6485183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030493Medicaid
MS2503185Medicare UPIN