Provider Demographics
NPI:1003821604
Name:REALO DISCOUNT DRUG STORE
Entity Type:Organization
Organization Name:REALO DISCOUNT DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BIZZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-527-6929
Mailing Address - Street 1:1302 W VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504-3528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1302 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-3528
Practice Address - Country:US
Practice Address - Phone:252-523-6069
Practice Address - Fax:252-523-3497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07673333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3438339OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC0545574Medicaid