Provider Demographics
NPI:1013015049
Name:EXTENSIVE PHARMACEUTICAL SERVICES, INC.
Entity Type:Organization
Organization Name:EXTENSIVE PHARMACEUTICAL SERVICES, INC.
Other - Org Name:EXTENSIVE PHARMACEUTICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:252-527-1593
Mailing Address - Street 1:306 N QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-4932
Mailing Address - Country:US
Mailing Address - Phone:252-527-1593
Mailing Address - Fax:252-527-1893
Practice Address - Street 1:306 N QUEEN ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-4932
Practice Address - Country:US
Practice Address - Phone:252-527-1593
Practice Address - Fax:252-527-1893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NC102683336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0545681Medicaid
3430763OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0545681Medicaid