Provider Demographics
NPI:1871688457
Name:BOONEVILLE DISCOUNT DRUGS INC
Entity Type:Organization
Organization Name:BOONEVILLE DISCOUNT DRUGS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:DUCKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:662-728-7781
Mailing Address - Street 1:P.O BOX 330
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829
Mailing Address - Country:US
Mailing Address - Phone:662-728-7781
Mailing Address - Fax:
Practice Address - Street 1:417A NORTH SECOND STREET
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829
Practice Address - Country:US
Practice Address - Phone:662-728-7781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS006943336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00037443Medicaid