Provider Demographics
NPI:1174650998
Name:NEW MASSEY HILL PHARMACY LLC
Entity Type:Organization
Organization Name:NEW MASSEY HILL PHARMACY LLC
Other - Org Name:MASSEY HILL DRUG CO.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SRIDHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTIPATI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-484-0159
Mailing Address - Street 1:1072 SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-1766
Mailing Address - Country:US
Mailing Address - Phone:910-484-0150
Mailing Address - Fax:910-484-3270
Practice Address - Street 1:1072 SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-1766
Practice Address - Country:US
Practice Address - Phone:910-484-0150
Practice Address - Fax:910-484-3270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3406091OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0267534Medicaid
NC6379660001Medicare NSC