1538200456 NPI number — SELF MED RX MAIN STREET PHARMACY INC

Table of content: (NPI 1538200456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538200456 NPI number — SELF MED RX MAIN STREET PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SELF MED RX MAIN STREET PHARMACY 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:
Provider Other Organization Name Type Code:
6
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:
1538200456
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6827
Provider Second Line Business Mailing Address:
C/O SELF MED RX INC
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-342-6450
Provider Business Mailing Address Fax Number:
404-614-0322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGHLANDS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-526-8845
Provider Business Practice Location Address Fax Number:
828-526-2367
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BENTLEY
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
800-342-6450

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  08061 , 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: 3439646 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0565200 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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