1063646933 NPI number — SERVANT PHARMACY OF RALEIGH LLC

Table of content: (NPI 1063646933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063646933 NPI number — SERVANT PHARMACY OF RALEIGH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERVANT PHARMACY OF RALEIGH LLC
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:
SERVANT PHARMACY OF RALEIGH, LLC
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:
1063646933
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2451 CUMBERLAND PKWY SE
Provider Second Line Business Mailing Address:
SUITE 3694
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-6136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-303-1680
Provider Business Mailing Address Fax Number:
678-303-1686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 PONY RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZEBULON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27597-2656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-827-0528
Provider Business Practice Location Address Fax Number:
678-303-1686
Provider Enumeration Date:
05/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
KROLL
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
678-303-1680

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 10294 , 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: 2120320 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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