Provider Demographics
NPI:1053493841
Name:FAMILYMED PHARMACY OF MAIDEN
Entity Type:Organization
Organization Name:FAMILYMED PHARMACY OF MAIDEN
Other - Org Name:FAMILYMED PHARMACY OF MAIDEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHULL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:828-428-1501
Mailing Address - Street 1:625 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAIDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28650-1419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MAIDEN
Practice Address - State:NC
Practice Address - Zip Code:28650-1419
Practice Address - Country:US
Practice Address - Phone:828-428-1501
Practice Address - Fax:828-428-4138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC090283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0186256Medicaid
3402827OtherNCPDP PROVIDER IDENTIFICATION NUMBER