Provider Demographics
NPI:1093757692
Name:WEBSTERS PHARMACY
Entity Type:Organization
Organization Name:WEBSTERS PHARMACY
Other - Org Name:BRADYS PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ PHARMACY MGR
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-628-6362
Mailing Address - Street 1:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28340-0741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1904
Practice Address - Country:US
Practice Address - Phone:910-628-6362
Practice Address - Fax:910-628-9334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC036063336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0785295Medicaid
3405998OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0785295Medicaid