1063538742 NPI number — PIEDMONT HEALTH SERVICES, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063538742 NPI number — PIEDMONT HEALTH SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIEDMONT HEALTH SERVICES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHARLES DREW COMMUNITY HEALTH CENTER PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063538742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 N GRAHAM HOPEDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27217-2971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-532-0414
Provider Business Mailing Address Fax Number:
336-570-3752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 N GRAHAM HOPEDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27217-2971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-532-0414
Provider Business Practice Location Address Fax Number:
336-570-3752
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MASON
Authorized Official First Name:
LYDIA
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
919-933-8494

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  15707 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0002X , with the licence number: 06027 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 34-4515B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 06027 . This is a "NC BOP PERMIT #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3432060 . This is a "NABP #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: NC AC 0000 1130 . This is a "NC CONTROLLED SUBSTANCE #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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