1821387911 NPI number — GUARDIAN PHARMACY OF EASTERN NC, LLC

Table of content: (NPI 1821387911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821387911 NPI number — GUARDIAN PHARMACY OF EASTERN NC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF EASTERN NC, 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:
1821387911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT # 2435 GUARDIAN PHARMACY OF EASTERN NC
Provider Second Line Business Mailing Address:
P.O. BOX 11407
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-810-0089
Provider Business Mailing Address Fax Number:
404-810-0094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4459 TARHEEL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINK HILL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28572-9649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-568-9945
Provider Business Practice Location Address Fax Number:
866-928-3983
Provider Enumeration Date:
03/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
TERRY
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-PRESIDENT
Authorized Official Telephone Number:
866-768-8479

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 10966 , 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: 2130223 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1821387911 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1821387911 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7N0965 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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