1962704775 NPI number — SPECIALTY PHARMACY-SOUTHERN PINES LLC

Table of content: (NPI 1962704775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962704775 NPI number — SPECIALTY PHARMACY-SOUTHERN PINES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALTY PHARMACY-SOUTHERN PINES 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:
SPECIALTY PHARMACY-SOUTHERN PINES, 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:
1962704775
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
735 S BENNETT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHERN PINES
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28387-5921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-246-9355
Provider Business Mailing Address Fax Number:
910-246-1755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
735 S. BENNETT ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHERN PINES
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-246-9355
Provider Business Practice Location Address Fax Number:
910-246-1755
Provider Enumeration Date:
11/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WATERS
Authorized Official First Name:
WESLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-691-1022

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 10686 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3458191 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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