Provider Demographics
NPI:1033271002
Name:PHARMACY OF J IVERSON RIDDLE DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:PHARMACY OF J IVERSON RIDDLE DEVELOPMENT CENTER
Other - Org Name:J IVERSON RIDDLE DEVELOPMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHCY SVCS
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEARINGEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:828-433-2683
Mailing Address - Street 1:CBO DHHS CONTROLLERS OFC
Mailing Address - Street 2:2021 MAIL SERVICE CENTER
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27699-0001
Mailing Address - Country:US
Mailing Address - Phone:919-733-9867
Mailing Address - Fax:919-733-1512
Practice Address - Street 1:300 ENOLA RD
Practice Address - Street 2:PHARMACY DEPARTMENT
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4608
Practice Address - Country:US
Practice Address - Phone:828-433-2653
Practice Address - Fax:828-433-2894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336I0012X
NC026773336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2066483OtherPK
NC3406014Medicaid