1790111961 NPI number — REALO DISCOUNT DRUG STORES OF ENC, INC

Table of content: (NPI 1790111961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790111961 NPI number — REALO DISCOUNT DRUG STORES OF ENC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REALO DISCOUNT DRUG STORES OF ENC, 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:
1790111961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1301 COMMERCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BERN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-639-9006
Provider Business Mailing Address Fax Number:
252-639-9005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5655 S NC 41 HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLACE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-285-1120
Provider Business Practice Location Address Fax Number:
910-285-1124
Provider Enumeration Date:
09/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MCLAUGHLIN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
252-639-9006

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  11618 , 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: 11618 . This is a "NCBOP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1790111961 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: C978 . This is a "MEDICARE FLU" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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