Provider Demographics
NPI:1083997530
Name:STANLEYVILLE FAMILY PHARMACY, INC
Entity Type:Organization
Organization Name:STANLEYVILLE FAMILY PHARMACY, INC
Other - Org Name:STANLEYVILLE FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:336-377-3979
Mailing Address - Street 1:193 N SUMMIT SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105
Mailing Address - Country:US
Mailing Address - Phone:336-377-3979
Mailing Address - Fax:336-377-9979
Practice Address - Street 1:193 N SUMMIT SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105
Practice Address - Country:US
Practice Address - Phone:336-377-3979
Practice Address - Fax:336-377-9979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10263333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0347748Medicaid