Provider Demographics
NPI:1114016763
Name:SCOTTIE DRUGS OF WALLACE INC
Entity Type:Organization
Organization Name:SCOTTIE DRUGS OF WALLACE INC
Other - Org Name:SCOTTIE DRUG STORES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUISNESS MGR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-285-4187
Mailing Address - Street 1:114 NE RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-2921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 NE RAILROAD ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-2921
Practice Address - Country:US
Practice Address - Phone:910-285-4187
Practice Address - Fax:910-285-7824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC03611333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0315150Medicaid
3411864OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NC0315150Medicaid