Provider Demographics
NPI:1154483220
Name:REALO DISCOUNT DRUG STORES OF JOHNSTON COUNTY, INC
Entity Type:Organization
Organization Name:REALO DISCOUNT DRUG STORES OF JOHNSTON COUNTY, INC
Other - Org Name:REALO DISCOUNT DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEQUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:919-934-2111
Mailing Address - Street 1:601 N 8TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-4119
Mailing Address - Country:US
Mailing Address - Phone:919-934-2111
Mailing Address - Fax:919-934-2814
Practice Address - Street 1:601 N 8TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4119
Practice Address - Country:US
Practice Address - Phone:919-934-2111
Practice Address - Fax:919-934-2814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3411080OtherNCPDP
NC0515652Medicaid
NC0515652Medicaid
NC3411080OtherNCPDP