Provider Demographics
NPI:1114039260
Name:GENE ANDERSON DRUG STORE INC.
Entity Type:Organization
Organization Name:GENE ANDERSON DRUG STORE INC.
Other - Org Name:GENE ANDERSON DRUG STORE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:GIBSON
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-862-8411
Mailing Address - Street 1:PO BOX 1749
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-1749
Mailing Address - Country:US
Mailing Address - Phone:910-862-8411
Mailing Address - Fax:910-862-8775
Practice Address - Street 1:206 SOUTH POPLAR STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337
Practice Address - Country:US
Practice Address - Phone:910-862-8411
Practice Address - Fax:910-862-8775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1114039260332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0095208Medicaid
NC7700957Medicaid
NC0572660001Medicare ID - Type Unspecified
NC7700957Medicaid