1811247257 NPI number — PROFESSIONAL SPECIALTY PHARMACY, LLC

Table of content: (NPI 1811247257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811247257 NPI number — PROFESSIONAL SPECIALTY PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL SPECIALTY PHARMACY, LLC
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:
1811247257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
142 ROXBORO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27565-2642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-603-3824
Provider Business Mailing Address Fax Number:
919-603-3847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
142 ROXBORO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27565-2642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-603-3824
Provider Business Practice Location Address Fax Number:
919-603-3847
Provider Enumeration Date:
09/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BOWMAN
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER/MANAGER
Authorized Official Telephone Number:
919-603-3824

Provider Taxonomy Codes

  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X , with the licence number: 11338 , 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: 3460401 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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