Provider Demographics
NPI:1043252497
Name:SEAGROVE ASSOCIATES LLC
Entity Type:Organization
Organization Name:SEAGROVE ASSOCIATES LLC
Other - Org Name:CAROLINA PHARMACY - SEAGROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHCY MGR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:336-873-8246
Mailing Address - Street 1:510 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SEAGROVE
Mailing Address - State:NC
Mailing Address - Zip Code:27341-8583
Mailing Address - Country:US
Mailing Address - Phone:336-873-8246
Mailing Address - Fax:336-873-8608
Practice Address - Street 1:510 N BROAD ST
Practice Address - Street 2:
Practice Address - City:SEAGROVE
Practice Address - State:NC
Practice Address - Zip Code:27341-8583
Practice Address - Country:US
Practice Address - Phone:336-873-8246
Practice Address - Fax:336-873-8608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC075513336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2068492OtherPK
NC0765578Medicaid
2068492OtherPK