1942201173 NPI number — FARMVILLE DISCOUNT DRUG, INC.

Table of content: (NPI 1942201173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942201173 NPI number — FARMVILLE DISCOUNT DRUG, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FARMVILLE DISCOUNT DRUG, 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:
BEST VALUE DRUG
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:
1942201173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27828-0690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-753-2092
Provider Business Mailing Address Fax Number:
252-753-2499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3708 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27828-1465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-753-2092
Provider Business Practice Location Address Fax Number:
252-753-2499
Provider Enumeration Date:
08/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CROCKER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
252-753-2092

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  03259 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 03259 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X , with the licence number: 03259 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 03259 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7700071 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6800352 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0745224 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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