Provider Demographics
NPI:1083672059
Name:MEDICAL VILLAGE PHARMACY, INC.
Entity Type:Organization
Organization Name:MEDICAL VILLAGE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SHOKES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:828-322-4505
Mailing Address - Street 1:815 FAIRGROVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-8609
Mailing Address - Country:US
Mailing Address - Phone:828-322-4505
Mailing Address - Fax:828-322-2669
Practice Address - Street 1:815 FAIRGROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-8609
Practice Address - Country:US
Practice Address - Phone:828-322-4505
Practice Address - Fax:828-322-2669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NC31323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0185355Medicaid
NC0185355Medicaid