1790041440 NPI number — COROLLA PHARMACY, INC

Table of content: MISS SARA ANN MOELLER PAC (NPI 1043565328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790041440 NPI number — COROLLA PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COROLLA 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:
1790041440
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOYOCK
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27958-0520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-232-0278
Provider Business Mailing Address Fax Number:
252-435-4063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
532 CARATOKE HWY STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOYOCK
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27958-8740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-232-0278
Provider Business Practice Location Address Fax Number:
252-435-4063
Provider Enumeration Date:
04/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TATUM
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHARMACIST-MANAGER
Authorized Official Telephone Number:
252-232-0278

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  7582 , 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: 0275073 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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