1720173396 NPI number — PEMBROKE DRUG CENTER

Table of content: (NPI 1720173396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720173396 NPI number — PEMBROKE DRUG CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEMBROKE DRUG CENTER
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:
1720173396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1030
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28372-1030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-522-0009
Provider Business Mailing Address Fax Number:
910-521-5654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4155 FERNCREEK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28314-2581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-485-7131
Provider Business Practice Location Address Fax Number:
910-485-7132
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-522-0001

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7704496 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com