Provider Demographics
NPI:1063646933
Name:SERVANT PHARMACY OF RALEIGH LLC
Entity Type:Organization
Organization Name:SERVANT PHARMACY OF RALEIGH LLC
Other - Org Name:SERVANT PHARMACY OF RALEIGH, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-303-1680
Mailing Address - Street 1:2451 CUMBERLAND PKWY SE
Mailing Address - Street 2:SUITE 3694
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6136
Mailing Address - Country:US
Mailing Address - Phone:678-303-1680
Mailing Address - Fax:678-303-1686
Practice Address - Street 1:700 PONY RD STE A
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-2656
Practice Address - Country:US
Practice Address - Phone:919-827-0528
Practice Address - Fax:678-303-1686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-07
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC102943336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120320OtherPK