Provider Demographics
NPI:1134507775
Name:BLACK RIVER HEALTH
Entity Type:Organization
Organization Name:BLACK RIVER HEALTH
Other - Org Name:MAPLE HILL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ALVANOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:910-259-8880
Mailing Address - Street 1:4811 NC HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:MAPLE HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28454-8153
Mailing Address - Country:US
Mailing Address - Phone:910-259-8880
Mailing Address - Fax:910-259-4144
Practice Address - Street 1:4811 NC HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:MAPLE HILL
Practice Address - State:NC
Practice Address - Zip Code:28454-8153
Practice Address - Country:US
Practice Address - Phone:910-259-8880
Practice Address - Fax:910-259-4144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-15
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5080210001332B00000X
NCNC084083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0715269Medicaid
NC3426663OtherNABP