Provider Demographics
NPI:1164596318
Name:HALLS DRUG STORE LLC
Entity Type:Organization
Organization Name:HALLS DRUG STORE LLC
Other - Org Name:YOUR PHARMACY OF LEXINGTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OPERTAIONS
Authorized Official - Prefix:
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-857-7227
Mailing Address - Street 1:100 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-2362
Mailing Address - Country:US
Mailing Address - Phone:336-249-0322
Mailing Address - Fax:336-249-8572
Practice Address - Street 1:100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-2362
Practice Address - Country:US
Practice Address - Phone:336-249-0322
Practice Address - Fax:336-249-8572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NC108973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128743OtherPK
NC0295921Medicaid