Provider Demographics
NPI:1164560009
Name:SOUTHERN PINES PRESCRIPTION SHOP INC
Entity Type:Organization
Organization Name:SOUTHERN PINES PRESCRIPTION SHOP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-315-4445
Mailing Address - Street 1:300 S MIDDLETON ST
Mailing Address - Street 2:P.O. BOX 548
Mailing Address - City:ROBBINS
Mailing Address - State:NC
Mailing Address - Zip Code:27325-8407
Mailing Address - Country:US
Mailing Address - Phone:910-948-2921
Mailing Address - Fax:910-948-3477
Practice Address - Street 1:300 MIDDLETON ST
Practice Address - Street 2:
Practice Address - City:ROBBINS
Practice Address - State:NC
Practice Address - Zip Code:27325
Practice Address - Country:US
Practice Address - Phone:910-948-2921
Practice Address - Fax:910-948-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC103913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123091OtherPK
NC1164560009Medicaid