Provider Demographics
NPI:1093005217
Name:REALO DISCOUNT DRUG OF POLLOCKSVILLE
Entity Type:Organization
Organization Name:REALO DISCOUNT DRUG OF POLLOCKSVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:H
Authorized Official - Last Name:KILLINGSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:252-229-8124
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0027
Mailing Address - Country:US
Mailing Address - Phone:252-224-0404
Mailing Address - Fax:252-224-0406
Practice Address - Street 1:9041 HWY 17
Practice Address - Street 2:
Practice Address - City:POLLOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28573-0027
Practice Address - Country:US
Practice Address - Phone:252-224-0404
Practice Address - Fax:252-224-0406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC109993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6702290001Medicare NSC